Mr Nik Bakti

Vicky

Okay, good evening. Everyone. Welcome to our webinar on shoulder pain treatment and surgery. My name is Vicky, and I'm your host this evening.

I'm joined by our presenters, Consultant Orthopaedic Surgeons, Mr Nik Bakti and Mr Daniel Neen.

This presentation will be followed by a question-and-answer session. So if you'd like to ask a question during or after the presentation, please do so by using the Q&A icon which is at the bottom of your screen.

This can be done with or without giving your name. Please note that this session is being recorded. If you do provide your name.

If you'd like to book your consultation, we'll provide contact details at the end of this session. And I'll now hand over to Mr Neen and Mr Bakti.

Daniel Neen

Thank you very much. Right, good evening, everybody. Thank you very much for joining us this evening.

We're going to be talking a little bit around the realm of shoulder pain and what we can offer here at Benenden, and sort of other types of treatment that we can offer as well.

So to introduce myself a little bit further. As said, I'm an Orthopaedic Consultant Surgeon, and I graduated quite a long time ago. Now it feels like 1999 from London and then went through the usual training I actually trained in this area in the South-East.

And I've trained with a lot of the older Consultant Surgeons in the area.

I then went on to have some fellowship training which is a type of training that we do with surgical training, where we specialize even further in our subspecialty field.

And I went to Exeter and to New Zealand for a while and then came back and started my consultancy in Dartford and Sidcup NHS trust there in 2015.

I was invited to join Benenden the year after that and things have progressed along the way, and I'm now a Clinical Director of Queen Mary's Hospital in Sidcup itself.

I'm proud to say that I brought along the shoulder replacements, anatomic and reverse, to Dartford and Gravesham, and introduced them back when I first started, and things progressed again with this.

So I'm now performing about 40 replacements a year, and the average is about 17.

So myself and my colleague, Mr Bakti, perform all of the replacements at our NHS Trust, and also perform them here at Benenden but we'll come on to that later on.

And now introduce my colleague, Mr Bakti.

Nik Bakti

Evening everyone. My name is Nik Bhakti, and, like Mr Neen. I'm one of the orthopaedic consultants here as well as Darren Valley Hospital. I graduated from Guys Kingston's Thomas Hospital in 2008.

I did my initial surgical training in Oxford and went on to do my surgical specialist training in Kent in this region. I was actually Mr Neen's trainee not too long ago.

I went on to do my fellowship in Australia for about nine months, where I specialized in sports orthopaedic surgery and shoulder replacement surgery, and I started in Durham Valley Hospital in 2022

Since then I've been appointed as the trauma lead for the Trust.

and I'm also a visiting lecturer at the Canterbury Christ Church University.

So now that we've done introductions. Today, what we're going to cover this evening is a little bit about the anatomy of the shoulder.

What can go wrong, a lot of things can go wrong, surely, but we'll cover the common ones.

We'll discuss what treatments we can offer for those common ailments, and we will finish off with a short question and answer session at the end.

So shoulder pain and symptoms are very common. It tends to increase with age. It can be secondary to dislocations, trauma fractures, but it can also be due to repetitive work or sports.

Sometimes it can be secondary to no particular problems. And this is this can be the case in frozen shoulder, and we'll discuss that later.

But it can also be due to degenerative problems due to wear and tear, such as rotator cuff injury and arthritis of the shoulder and again, we'll discuss this later.

About one to 2% of patients who present to the GP present with shoulder problems. And about 70% of this is related to what we call subacromial pain and that is the area in the shoulder that's right above the ball and socket joint.

It doesn't seem to be that's important on an X-ray, but in that space itself there is tendons that help move the shoulder. But there's also a little pillow that's fluid filled that can get inflamed, and in this particular conditions called bursitis can cause quite a lot of symptoms.

Sometimes in that area there is a bony spur that arises from the acromion, and it can cause symptoms what is commonly referred to as impingement, and that can cause quite a lot of problems with overhead activities.

So if your job requires you to do lots of overhead movements, this can be quite debilitating.

The shoulder joint itself as a whole is quite unstable.

The reason for this is that the shoulder joint itself has to be quite mobile for us to get our hand to where we want it to be.

Unlike the hip joint, where it's a deep socket. The shoulder joints is not and the stability of the shoulder is very much given by the muscles and tendons around it.

So this picture, this image here shows the ball and socket joint for the shoulder, and the ligaments around it, and the tendons around it.

The tendon that crosses the shoulder joint itself is the long head of biceps, and in some conditions can be irritated, can be inflamed, and can cause quite a lot of pain.

The tendon itself crosses the joint in the capsule and in certain conditions, such as frozen shoulder or adhesive capsulitis, can get very inflamed, and this results in symptoms such as stiffness and ongoing pain.

This slide here shows how complex the tendons and muscles around the shoulder is and it will bring us on to how important physiotherapy is in managing shoulder pathology or pain.

The key bit in this slide is to show the components or the muscles and tendons that make up the rotator cuff.

There are four main muscles, this subscapularis, the supraspinatus, the infraspinatus, and the teres minor and apart from shoulder stability, these muscles and tendons help with movement of the shoulder.

The tendon that's most commonly injured or damaged in rotator cuff problems is the supraspinal tendon.

Around these tendons would be the deltoid and the pec major muscle. And again, they are very important in physiotherapy in helping treat shoulder problems.

This is again another image to just show how closely related the shoulder joint is with the muscles around it.

And I'm going to hand you back to Mr Neen to talk about treatments for shoulder pathology.

Daniel Neen

Thank you very much. Right, yes, so treatment for pain and injuries obviously, would very much depend on what sort of diagnosis we come to all sorts of things, can cause the pain, as mentioned by Mr Bakti.

This even includes things coming from your neck, so the neck can cause pinching of a nerve that supplies the area. So part of our job is really to give you the diagnosis as to why you're getting the pain. In the first place.

once we've reached that diagnosis, we can then suggest various treatment modalities. Physiotherapy is by and large the 1st stage of all treatments and a lot of the people we see have already had that physiotherapy commenced by their GP for example or have sought physiotherapy themselves.

Osteopathy can also play a role in this and increasingly is doing so actually.

If we have a diagnosis of inflammation within the shoulder, then one of the very powerful tools that we can use is a steroid injection.

And that's a very strong anti-inflammatory. It's not the type of steroids that people use to build up muscles. That's a different type of steroid.

They're very much more along the lines of the anti-inflammatories that you can buy in a chemist, such as ibuprofen or diclofenac on prescription.

But those are non-steroidal anti-inflammatories. We use a steroidal anti-inflammatory. So again, this can be injected right into the area where you're getting a lot of the inflammation can help matters.

Even if it doesn't last long, it can be diagnostic in its use as well.

If all these modalities have been tried. So time rest changing what you do, physiotherapy, even a steroid injection and we're sure of the diagnosis but things still haven't cleared up. Then surgery does have a role to play.

The vast majority of things do seem to clear up on their own, though with the sort of conservative or non-operative management that we use.

If you come to an operation. There are various things that we can do, and it does again depend on really what the underlying diagnosis is. A lot of the soft tissue procedures that we do these days are keyhole surgery, otherwise known as arthroscopic.

And it involves very small holes being made around the shoulder girdle for us to introduce these tools that we use to cut or remove or fix and repair.

As you can see on the slide. There are various things that we can do with tendons from repairing them.

We can stabilize the shoulder itself. We can release the shoulder in things like frozen shoulder, or we can even replace the joint itself, but that is more of an open procedure.

Physiotherapy itself is as discussed one of our mainstay of treatments.

We've already talked about how unstable. The joint is potentially, and if you have a degree of instability, then balancing that joint is a very important proponent, and the physiotherapists do their best to sort of balance the front and back muscles.

Some of this is also involved in posture, and increasingly, these days we're bending over desks for hours at a time with our shoulders hunched forwards, and this, we know, encroaches on the tendons underneath the acromion bone at the top the ledge of bone that you can feel.

Exercises will help maintain tone of the muscles, help keep the joints supple and hopefully help with the inflammation.

But again, it's not a quick fix. It does take quite a few sessions of physiotherapy and maintaining that balance to then have the prolonged effects and benefits.

One of the key things that physiotherapists, and indeed, Mr Bakti and I see, is a diagnosis called impingement.

If we go back, about 70% of pain that comes from a shoulder will involve this diagnosis.

We've talked about the acromion, which is the little ledge of bone across the top, and underneath that there's a cushion called the bursa, and underneath that is the tendon supraspinatus at the top before the joint itself.

And what happens either depends on the movement of the joint itself, or the way that you use it, or indeed, it can just be due to wear and tear itself. But the tendon, the supraspinatus, which is the most common tendon involved in this encroaches on the bone or starts to peel off its attachment and wear out.

This can cause inflammation not only in the tendon itself a tendinitis, but also the bursa above it. So that's a bursitis, and both of those can cause a lot of pain, particularly with certain movements.

One of the anatomical things that can happen to cause this is that bone above it can be curved.

So some people have a flat ledger bone. Some people have a curved ledger bone, and depending on the amount of curvature, will depend on how much room that tendon has to move.

We can see them. The spurs of bone quite clearly, usually on an X-ray, and it appears on this front, facing X-ray, the ball and socket side by side, and then this acromial ledge above, with a spur of bone, and, as you can see, it's sitting right above the head, just where that tendon would normally fit.

You won't see a tendon, or you won't see cartilage on an X-ray, because neither of those have got calcium in them, so they don't show up on the image.

However, there is a way of looking at the soft tissues, the calcium, and the cartilage, with various other forms that we use of imaging. This is called an MRI scan, and so this image we can see exactly the same as the X-ray, but the gap in between the bone, above and below you can see that there is an image of a tendon, and that green arrow points to a little area above it, which is inflammation, and the red arrow points to a gap in that tendon where it normally attaches down to the ledge of bone to help move it.

It's detached and you see this bright white area where more fluid is present. So this is a torn tendon.

A little animation here of what impingement is. So as you take that arm out to the side that ledge of bone where the tendon attaches rubs up underneath the acromion causing more pain.

So what do we do. As I've already discussed, physiotherapy, maybe an injection to help diagnose it, and to relieve it, and sometimes that's all that's necessary.

But if it fails to alleviate, unfortunately, it does sometimes come to surgery or, fortunately, as you may see it, there is something we can do.

So keyhole surgery, as this little animation demonstrates, is designed to bur away and under surface of that acromion and in doing so we create more room for that tendon to move.

The operation itself is day surgery. So you're in just for the day, although it still does involve a general anaesthetic meaning you're asleep.

You're in a sling, usually just for a couple of days, but can be longer just for comfort reasons. And then we're expecting people. Most people to return to work within three to six weeks.

Usually two little holes, about four each are used to do the actual operation and they heal within a couple of weeks.

And I'll hand you over to Mr Bakti to talk about the next common diagnosis we see.

Nik Bakti

So the next common diagnosis that I want to talk about is frozen shoulder. But it is also often referred to adhesive capsulitis.

So this is one of those insidious onset problems to your shoulder that starts off often spontaneous, sometimes can be due to trivial trauma, where you just knocked your shoulder at the side of the door, and it progressively gets more painful and more importantly stiff.

The pain and the stiffness becomes quite unbearable. Sometimes it can be a problem at night waking you up at night, and the biggest issue is in most of the patients that I see.

This is what we call idiopathic, where we don't actually know the cause of frozen shoulder.

As I mentioned before, it can be quite debilitating, especially when you are unable to get a good night's sleep, due to the pain the stiffness often sets in later after a few months, and then the pain settles, but the stiffness tends to stay there if the inappropriate treatment is not started.

The underlying problem in frozen shoulder is that the lining of the joint or the capsule itself gets very inflamed, and with time it scars down, and because of the scarring it's no longer supple.

It affects your movement. It is when it's inflamed, that's when the shoulder is painful.

The mainstay of treatment of frozen shoulder is physiotherapy. The problem that most of my patients complain of is that they are unable to do the physiotherapy and stretches because of the pain.

So secondary to the physiotherapy. Our treatments often involve pain management and this can either be a steroid injection into the shoulder.

Sometimes this can be done in clinic, but often this is done under X-ray guidance or ultrasound guidance.

If movement is an issue on top of the pain or stiffness is an issue on top of the pain.

Then there is a secondary or a different kind of injection that can be given, and this is termed hydrodistension. When lots of fluid saline is put into the shoulder to expand the capsule that has previously been scarred to help, not only with the pain, but also the movement.

Often this takes months on top of the injection and the hydro extension and physiotherapy, but after a period of trial of conservative treatment with this treatment.

If your movement is no better, then surgery can be considered. Most patients with frozen shoulder resolve without surgery.

If surgery is needed. Then, again, it's very similar to an impingement operation where it's done again as a keyhole operation again as a day surgery, but under general anaesthetic.

Where, whilst asleep, the shoulder is put through a range of motion to help with the stiffness and then a camera is put into the shoulder, where the scarred capsule is then released to help with the movement

Again following the operation. You'll be in a sling for a couple of days, and very importantly, after the operation is to not stay in the sling for too long, as then the stiffness might reconstitute.

Physiotherapy is key to help you get your range of motion and strength again and often patients do get back to work and driving within three to six weeks, depending on the nature of your job.

The next big diagnosis that we often see is rotator cuff injury.

The two main groups of rotator cuff injury. One is traumatic when you fall, or you have an injury to have torn your rotator cuff and the other is due to wear and tear, possibly due to a spur at the top of your acromion.

The symptoms that you get with rotator cuff injury is the inability or pain in doing overhead movements, and often this is associated with weakness in these movements.

As mentioned earlier, the tendon that's most likely to be involved is the supraspinatus tendon. But any of these four can be injured or torn.

The most common way to diagnose this is an ultrasound scan, and this is widely available in your GP practice in musculoskeletal clinics, and therefore it's often offered to patients.

It's a good way to assess for cuff problems, because it's readily available, and sometimes patients are unable to do further imaging such as an MRI scan.

But in my opinion, an MRI scan it's much more revealing, as it tells us, not only about the tear itself, but it also tells us how far the tear has progressed, and it gives us an idea whether it's repairable.

Based on how much it's retracted and whether the muscle itself is still viable. So in most of my patients. If we are considering rotator cuff surgery, then I would almost certainly, unless there's a reason not to carry out an MRI scan to give me a better idea of your shoulder.

Once that has been confirmed, then we discuss options of treatment. Not all cuff tears have to be treated with an operation.

This is particularly true for partial thickness cuff tears, quite a lot of patients or members of the public have a partial thickness cuff tear.

Most of us don't even know we have a partial thickness calf there, and often this is an incidental finding on either an ultrasound scan or an MRI scan this partial thickness cuff tears can be treated without an operation, often with physiotherapy and time, but sometimes require an injection to help calm any inflammation around there.

The cuff tears that have to have or should be considered for an operation are full thickness cuff tears that hasn't responded well to physiotherapy and injections or traumatic cough tests that would be cuff tears that has happened following an injury such as a fall or a dislocation.

So again, most cuff repairs are done as a day case, and most of them can be done keyhole.

Very few of cuff tears are not possible to be done using keyhole treatment or methods and sometimes will require a slightly bigger incision or a cut in order for us to access it.

But in my experience, 95% to 99% of cuff tears can be dealt with using keyhole operation

Similar to impingement operations, this is done as a general anaesthetic as a day case.

And what happens during the operation is that we identify the tear. We then freshen up the tear so that it has the potential to heal onto the bone, or where it's supposed to be attached.

We will then place what we call anchors into the bone. These are plastic anchors, so traditionally they were metallic anchors.

But now we've got improvement in materials that will allow us to do this, using plastic anchors which are less damaging to the bone and allow us to carry out further imaging in the future if needed.

So with this anchors there are some sutures that will then use to grab the tendon that's torn and we will cinch it down to the bone.

The difference between rotator cuff surgery compared to frozen shoulder surgery and impingement surgery is that following the repair the immobilization.

A sling is slightly longer anytime anything between four and six weeks, and this is to allow the repair tendon to settle into the bone, and if we don't do this, then there's a higher increase or higher chance of failure of the repair

Following the immobilization in a sling, then physiotherapy is key, first to get rid of the stiffness in the shoulder, so your range of motion, and then the second part of the recovery and the physiotherapy is to get back your strength into the muscles.

Often patients are back driving at about six weeks, patients with more manual work then they tend to go back slightly later. But if you are more office based, then often they're back at work. At about six weeks or so.

I'll pass you back on to Mr Neen to discuss shoulder arthritis.

Daniel Neen

Okay for our final topic, then shoulder arthritis, just like any joint in our bodies, we can develop arthritis in the shoulder.

And in essence arthritis is the wearing away or the eating away of the cartilage lining the joints. The cartilage is what gives it its slippery surface.

Cartilage has no feeling. You can do what you like to it. It won't cause any problems, but once the cartilage is gone, the underlying bone does have feeling, and that's where the inflammation and the pain starts coming into play.

In this particular X-ray. We can see. I don't know if you can see the difference between the ones we've the images we've shown beforehand. But this ball is now ridden up underneath that acromion, and in fact, the acromion looks like it's wearing away quite considerably, and it's come out of its socket as that arthritis progresses and the bone is rubbing on the bone on two occasions there.

There are different forms of the arthritis. This is one extreme example of this, but it can be due to either degenerative changes that we normally get, or an inflammatory process, or it can be a traumatic process after an injury to the joint itself.

Very commonly people will have good and bad days to start off with, with the good days outweighing the bad days.

But then, more and more it can be that the bad days start impeding things that they can do during the day activities of daily living, such as dressing yourself or cleaning yourself.

And the pain can become quite intrusive. So keeping you awake at night is one of the key things that we look for.

Another thing that people talk about when moving their arthritic joints, the clicking noises, or the creaking noises that they can sometimes get is the bone grinds on the surface.

On this occasion we can see that there's a large lump that has grown a bone at the bottom aspect of the ball, with a small loose fragment at the top. And this is another form of arthritis that we can see on an X-ray.

It's called an osteophyte, and they do become more common with the damage to the joint surface. As the joint tries to spread the weight of the load out.

And on this one is another typical finding of arthritis. You can see there's absolutely no gap, really, between the two bones. You can just about make out the ball and the socket where they used to be, but no gap between the bones, and that is bone on bone arthritis. And again, that potentially can be very painful.

Treatment wise really would depend on how severe things are getting.

If it's not affecting you too badly, then physiotherapy, just to maintain the muscles and the tone of the muscle and the range of movement as best you can, would be the mainstay of treatment.

This is a progressive disease. Unfortunately, it does gradually get worse, certainly on the X-rays, but the symptoms don't necessarily match X-rays. It gives us the underlying diagnosis.

But pain is the main thing that we're interested in treating, and we know that we can help.

If it becomes moderate. Then there are certain things that we can do with arthroscopy and keyhole surgery to debride or clean up the joint itself.

But again, the progression of the disease is not going to be halted altogether by doing it. So we are basically buying some time

When it gets to severe symptoms, pain wake you up at night, or things really getting desperate during the day.

Then we discuss alternatives, and one such alternative would be a shoulder replacement just again, much as most people have heard about hip replacements and knee replacements which are very common in this country.

Shoulder replacements are becoming more common and it's surprising that more and more people are knowing about it interestingly when they come in. They've never heard of a shoulder replacement before, but it is possible.

As discussed. Really, we would only be talking about it as a needs must surgery because it is a major undertaking. However, it's very effective at dealing with pain.

It certainly helps with mobility. It doesn't make it a normal joint by any means, but it can help with the mobility from a very stiff joint.

However, the stiffer the joint is beforehand the stiffer. It is afterwards as well, so we can't guarantee that range of movement, unfortunately, but the pain is something that we certainly do help with.

An interesting modality that we use is something called a reverse shoulder and a reason I bring this up is again a lot of people. Not only have they never heard of a shoulder replacement, but a lot of people had a lot of bad press about shoulder replacements because of what we used to do in the not-too-distant past.

We used to just replace one half of the shoulder, thinking that this was the best thing, we were replacing the painful joint surface.

But unfortunately we still had the other side being painful, and also, unfortunately, because of a lack of tendon. That metal surface would then ride out of its joint and start causing other issues elsewhere, and everything would be more painful and stiff despite the operation.

So back in the I think, he started in the eighties, but it certainly in the nineties. This gentleman, Grammont, came up with the idea of reversing the geometry of the shoulder, so the ball and socket, as we can see in the picture is normally situated on the left-hand side there.

But if you turn that socket into a ball and the ball aspect into a socket, you can actually make it so that the humerus or the arm bone itself cannot ride up underneath the acromion.

It also stretches out that side muscle there, the deltoid which means it's happier to do the movement, the lifting of the arm without the tendons that have disappeared on their own.

The system we use is called equinox. It's got a long track record. It's particularly used in America but has been over here for a number of years now, and we seem to have very good results from it.

It's good stability and it has a track. Record is improving and growing in evidence.

Should you come to shoulder surgery usually, as we talked about. It's a day admission. So you come in, come in, either on the morning or in the late afternoon, depending on when your appointment is.

You'll be greeted by the nursing staff up on the ward, the anaesthetist will come around and just check your general health and make sure that you're not currently ill.

You'll then be seen by the surgeon, maybe just to do some final checks and paperwork, and usually we put an arrow on the arm that we're going to be operating on.

You then have a general anaesthetic. So you're asleep. But they also usually offer you a nerve block, and what that is an injection in your neck, or the base of your neck near the nerves that go down your arm, so that when you wake up you have no pain.

Unfortunately, it's a bit of a weird feeling, I'm told in that you can't move your arm, but it's the pain aspect once again that we're trying to help with, and it doesn't last forever. It sort of usually works its way out within the first 24 hours.

During that time, however, it's very important that people take painkillers to keep up with the pain, so that they don't wake up with it, and then try and chase the pain, which is a very difficult situation.

If you're having a shoulder replacement or joint replacement, you tend to stay in one night.

And I think that's pretty much the longest time people stay in with shoulder surgery and arm surgery in general.

You have your arm in a sling until it wakes up, certainly, and then depending on what operation you've had will depend on how long you need to wear that sling for.

Physiotherapy is then commenced relatively soon after the operation and usually goes on for two or three months just to get you through the whole rehabilitation exercise process.

And so then you can carry on with your own exercises on your own.

Driving wise, most people ask about when they can drive. And again, it depends on what you have done. If it's something bigger, like a rotator cuff repair or a shoulder replacement. Then you're looking at about six weeks to attempt.

It doesn't mean that you have to drive. It's very much more confidence building exercise. And so when you feel able to. But it's usually from the six-week mark that you start trying.

Normal activities, well usually within the first three weeks we're hoping that the movements will have improved to about 50% of before the operation level of activity.

But passive movements. We want to have improved by about week 6. Now, passive means that somebody is moving the arm for you, or you're doing it with your other arm.

Active movements. We hope to be at least to the preoperative level by about three months. Driving, as I said, is about six weeks, or from six weeks.

People ask about golf, and that's about 12 weeks and swimming. And so it depends on the stroke that you use. Freestyle again, is a bit more active. And so we're looking from about 12 weeks.

Lifting weights after a shoulder replacement can begin fairly quickly with the physiotherapist's guidance. But we're talking about very light resistance, and any heavy items should be avoided for about six months, while that soft tissue reforms and stabilizes the joint itself.

Joint replacements are increasing in numbers, especially in this country. We're very fortunate to have a National Joint Registry in this country which I'll come onto in a second but it keeps track of how many joints are actually going in.

And, as we can see, shoulders were at the 8,000 mark. At this point in time there was a little dip in 2020 with Covid, but that was the same for everything where everything seemed to about halve.

But obviously we're nowhere near the order of hips and knees, which are over a hundred thousand operations per year.

Ankles and elbows are lagging behind. But again, I think there's just not the demand for that sort of replacement just at the present time, and technology is improving for them.

The National Joint Registry in this country is the biggest in the world, actually for shoulders. In particular, we started capturing the information about all the joint replacements going in since 2012.

As you can see, when we 1st started out it was about 35% of them were hemiarthroplasties. What that means is that we were replacing the ball component only out of the ball and socket joint. The socket was left alone.

About a quarter of them were then the ball and socket total replacements, and about a quarter again the reverse polarity ones.

But things have changed, and these hemiarthroplasties that are going out of favour. We tend to potentially do them in very young patients where we want to try and preserve the socket if we can.

But about 20% are now total shoulders. So we replace both the ball and the socket in the normal alignment. Anatomic replacement, as we call it.

63% are now the reverse polarities. And certainly in my practice, that's what I've seen. The vast majority are these reverses because they do so well, there's another 10% unconfirmed reverses, so that figure may even be closer to three quarters of all the shoulder replacements.

Technology is coming on and on, and both Mr Bakti and I are privileged to use 3D modelling. This helps us plan the operation. Before we actually go in, we take a CT scan. This allows us to build a 3D model of the shoulder blade, including the socket.

And in that way we are able to size and place the implant precisely and we can plan ahead of schedule, and seldom is it that we were having to go against what the plan was originally.

We also use navigated shoulder replacements now. So navigation is another level altogether. So once we've planned it, we're then able to use the technology available to us to actually guide where we place the drill holes, the plate itself.

We can see in real time where the drill is going. So this helps us avoid any accidental drilling into places we don't want to.

It helps us visualize where these screws are going to end up, and it helps reassure us as much as anything that we're putting this plate exactly where we wanted to. In the first place.

Vicky

Lovely. Thank you both a very interesting presentation. So we've now got some time for some questions.

So I'll start off with Ted and Ted says I'm age 90 years old, and I have right shoulder, full thickness, rotator, cuff, tear with proximal migration of the humorous. I'm not in pain but have limited use of my arm. I can't raise it above horizontal. My wife is disabled and dependent on me. Recommendation, please?

Daniel Neen

Okay, right. Good evening, Ted. Thank you very much for your question.

So you have what sounds like very much the X-ray that I demonstrated earlier with that proximal migration, that high riding of the humoral head up underneath the acromion.

That tear is a common finding that we see in people usually from the age of 70 onwards. So you're not alone by any means, but because of that proximal migration. The humeral head will then develop a degree of arthritis potentially and it will limit the movements that you have.

Now pain, not being a factor is an extremely good thing and that is the thing that we usually are going for with surgery and can guarantee that we sort of try and help. The movements are not something we can guarantee.

So as with all these things, it's always good to sort of talk you through your options, but physiotherapy may be a benefit to you.

Alternatively, some injections and some gentle stretching exercises may be of benefit as well.

Surgery, wise. If pain isn't an issue. Then I would probably not go down that route, I would probably say, avoid it, because the problem with surgery is that there are very small risks involved with it, and if you have no pain at all, and we try and do an operation, but potentially makes it painful for you, then you can actually end up in a worse situation.

So my recommendation, probably on that, would be to avoid the operation if possible. But also there will always nuances.

Vicky

Thank you for that. Next question. My shoulder hurts mainly at night, or when laying, leaning on it for a long time it disrupts my sleep, but I can get on fine with day-to-day tasks with a little stiffness.

Would you suggest waiting till it gets worse, or get it looked at before it does?

Nik Bakti

So thank you for the question. I think it's always an issue when it affects your sleep, because it just sets the tone for the day, and it becomes sometimes can be quite unmanageable.

So the issue here is that during the day it's not a problem, and you have little stiffness, and sometimes you wonder if it's coming from your neck.

And about 20% of patients that I see in clinic that has been referred for shoulder problems actually have a neck issue.

So I think it's quite difficult to say whether to leave it and wait until it gets worse. But my mantra, for this is to know what's going on so that we can nip it in the bud.

So if you feel that the problem is bad enough, I would recommend that. You see someone, it could be someone you have easy access to, like a physiotherapist or your GP.

To see where the problem might be coming from. Either your shoulder and your neck, get some simple imaging, such as an ultrasound scan, to see if there's any inflammation of the tendon, and it could be something as simple as posture, physiotherapy, or even an injection if there's nothing, major like a tear that needs dealing with.

So I would say, get it looked at sooner rather than later, and nip it in the butt.

Daniel Neen

It's quite interesting. We see a lot of people with night pain and I think a lot of this is to do with gravity. So when you're up during the day one, you have distractions to take your mind off it, but also your arm.

The weight of the arm is hanging down, whereas when you lie down at night time, the arm is then shoved up, you have no weight pulling it down, and that can actually squash the area that is inflamed already, and that aggravates the pain for you. And then with nighttime you have no distractions either.

Vicky

Thank you both and next question. My shoulder pain flares up and then settles down again. Is that pattern most likely due to osteoarthritis I have everywhere else, so I don't see why my shoulders should be exempt.

Daniel Neen

So flaring up and settling down absolutely can be a very arthritic type of picture it can be to do with what you do during the day. If you overuse the joint or use it for doing a lot of heavy lifting, for example.

Joint is damaged in essence with arthritis, and so that will stir up trouble. It will stir up the inflammation.

But then a lot of the other common conditions that we see in the shoulder. Also have this sort of clinical picture where the more you use them, the more it stirs up the inflammation, and the more painful it gets until the point that you can't use it.

So you rest it, and everything starts to settle down again. So unfortunately, there are lots of pieces to the jigsaw that we would have to put together. And although osteoarthritis is certainly one of the possibilities. I wouldn't say I could definitely say, it's that.

Vicky

Okay, thank you. Hope that was useful. And next question is for Milton and they ask, 20 years ago I suffered multiple fractures to the proximal humerus in a rock-climbing accident now have severe arthritis in the Glenohumeral joint.

Long, keen, long distance road cyclist. Despite restricted arm ability, I can ride my bike and currently manage to pain without painkillers.

If I have a shoulder replacement or fall off my bike on the artificial shoulder, would the consequences for me be greater than if I don't have the replacement?

Nik Bakti

Right, so thank you for your question. Well done managing at the moment, and it's injuries in the past like fractures it can set off arthritis.

I feel that if you're managing and it's not impinging on your day-to-day activities and the hobbies that you have. I think it's best to lay a shoulder replacement as long as you can.

As you correctly mentioned. If you did fall off your bike, and you have a shoulder replacement in place, the worst-case scenario is that you fracture around the stem of the shoulder replacement, and very rarely we can treat this without an operation, but often it means that we'll have to go in there and fix it.

Sometimes with the plates and some screws, and sometimes by having to revise the whole, construct itself, so it can have quite dire consequences if you fell off your bike with an artificial shoulder in place.

So I think, whilst you're managing without painkillers, and you're still able to do what you want to and can do, delay the need for any shoulder replacement.

 What do you think?

Daniel Neen

I absolutely agree, yeah. Quality the point with the artificial shoulders or joint replacements. It won't give you a normal feeling shoulder necessarily.

But it will help with the quality of your life. So if you are struggling with the pain particularly then I think that that's certainly something to explore, but it sounds like you're able to do everything you want to do, and you're coping with the pain at the moment.

So absolutely, I would continue as you are until you absolutely have to. You'll know when you want the operation.

Vicky

Lovely. Thank you both. Hope that was helpful to you, Milton.

Got time for another couple of questions. This one's for Anthony. I've just had a spur removed that was causing an impingement shoulder is more painful at night. How long does it take to recover?

Daniel Neen

Yeah, in general, we say that most people, if it's just an impingement surgery, i.e. Shaving away the bone and clearing away the bursa. Most people are getting better within the first three months.

Shoulders are peculiar things, though, and they can take longer than expected. Certainly, even if it's soft tissue type stuff that we're doing.

And so as with physiotherapy, we advise people that can take anywhere between six to nine months to improve.

However, what is problematic for you is the pain at night particularly, and one of the key things that we need to rule out or potentially look for is the development of frozen shoulder.

So we talked about frozen shoulder a bit before, and it can come on for no reason at all. But unfortunately, one of the reasons it can come on is after a trauma, and surgery is a type of trauma, so an unfortunate, very few people they do develop secondary complication of a frozen shoulder.

And so this is something that will be monitored in your recovery by your surgeon.

Other than that. Yeah, it can take months rather than weeks to get over this type of operation. Unfortunately.

Vicky

Okay, thank you. Next from Peter. What's the average lifespan of a shoulder replacement before it may need revision?

Nik Bakti

So great question, Peter. And I think this is why we have our National Joint Registry and I think, based on a few factors, such as why you need a joint replacement in the 1st place, and sometimes which implant you use, and what type of shoulder replacement you have so either an anatomic or reverse, it can last up to about 15 plus years.

Sometimes, if you have anatomic shoulder and if your tendons then get injured, then the need for revision may be sooner, or if you have other complications, such as fractures or dislocations, but in general, in a straightforward primary shoulder replacement, one can expect it to last between 12 to 15 years.

Daniel Neen

I think the latest. Yeah, I think that's correct. I think the latest data was that about 6% of shoulder replacements needed revision at about 10 years.

So it's a relatively low number.

Vicky 

Okay, lovely. Thank you. Next question is from Andrew, and he asks, Can keyhole surgery help my PVNS if diagnosed?

Nik Bakti

That's a very specific question that It's rare to get PVNS in the shoulder, but it can happen.

But like the knee where one of the treatments for PVNS is to remove the inflamed synovium, then, yes, potentially keyhole operation to remove all the inflamed capsule around the shoulder can help.

But the problem with PVNS is that there's a higher risk of recurrence. So it's the other treatments on top of the keyhole operation, such as medicines and possibly steroid injections, is the one that's going to help long-term treatment of PVNS.

Vicky

Okay, lovely, thank you. Our next question is from Robert and Robert asks, does Bursitis clear by itself? I have a torn tendon, and have been doing Physio for six months, still uncomfortable though.

Daniel Neen

So it's the underlying cause of the bursitis. That's the issue. Probably. We've discussed torn tendons in in the talk, and there are partial tears which are not too significant.

But there can be torn tendons that are fully torn, and the problem with a fully torn tendon is that there is no way that that tendon can get back down to the bone without help.

Now the bursitis is probably a secondary phenomenon. It could be due to the reason that you had the torn tendon, in the first place, with that impingement aspect of things that we were talking about.

So I think you you're going through the whole non operative phase at the present time six months is probably a very good time to say, let's reevaluate the situation at this point in time.

Six months with pain is quite something. So yes, I think it's probably time to reevaluate at this point and just come and talk to somebody about what to do if it's really still hurting you and causing symptoms.

Vicky

Okay, lovely, thank you. So I think we'll have to make this the last question from Ian. So Ian had surgery after a fall directly hitting his shoulder injection and physio didn't help.

He's had keyhole subacromial decompression and trimming of the collarbone also tendons that were rubbing were trimmed over a year and a half ago. He still has pain.

Recently had an X-ray shown significant separation of the clavicle, and the chromium also shown a false joint. What are your suggestions to help this problem? He's seeing a surgeon next month.

Nik Bakti

Quite a complicated question there, yeah, but not having any benefit of your X-ray. It sounds like the joints where the collarbone meets the shoulder blade known as the chroma clavicular joint, seems to have separated, and this is quite and it's a small joint, but it's quite an important joint, because it takes most of the load from the shoulder, and when it doesn't work properly it can cause quite an issue.

It sounds like that. Join is now incompetent, and we call it dissociated, and I think what you need would be to come and to see someone about it get some formal imaging on it, and if it is what I think it is, then you might benefit from reconstructing that joints.

But again, I don't have the benefit of your X-rays. So I think that you've given it enough time after your operation, and if that's the case. Then you may need something else doing to it.

Daniel Neen

It's quite interesting that the gap has increased fivefold. So when we take off, when we do this acromioclavicular joint, which is the joint between your collarbone and your shoulder blade. We actually just take off the end of the collarbone itself. As you've said. They're five millimetres, that's all that we want to take off to increase that gap. You've got a little space to take a bit more, but we want to preserve the ligaments, so we don't want to take too much.

With it having gone 26 millimetres now, that's quite an interesting number. But again, we're looking at all these images, whereas usually what we do is we use an image to confirm a clinical suspicion or diagnosis.

And so I think what we're missing from that clinically really is. Where is the pain and clinically, where is the pain and then we could maybe do some injections to diagnose where that pain is.

So if we were thinking it was the gap that you had the Acromioclavicular joint, we could numb that to see if that helps with the pain, because it may be that we're focusing on that area. And in fact, it's elsewhere that's causing it.

But that gap is quite a large one, so I'll be interested to know what's caused it.

Vicky

Okay, lovely. Thank you both very much. Sorry if we didn't answer all your questions, and if you've provided your name, we will answer via email.

So as a thank you for joining this session, we're offering 50% off the value of your consultation for a limited period. Call back from your dedicated Private Patient Advisor, an email with the recording treatment, information and loyalty reward points and updates on news and future events as well.

We'd be grateful if you could complete the survey at the end of this session to help us shape our future webinars.

If you'd like to discuss or book your consultation. Our Private Patient team can take your call until 8:30 this evening, or between 8am and 6pm Monday to Friday, using the number on the screen.

We've got some more events coming up next month on varicose vein treatments and hip and knee osteoarthritis, and you can sign up to these via our website.

So on behalf of Mr Bakti, Mr Neen, and the expert teams here at Benenden Hospital, I'd like to say, thank you very much for joining us this evening, and we hope to hear from you very soon. Thank you and goodbye.

Daniel Neen

Thank you.