Louise King

Good evening, everyone. Welcome to our webinar on shoulder replacement surgery. My name is Louise and I’m your host for this evening. Our expert presenter is Consultant Orthopaedic Surgeon, Daniel Neen. This presentation will be followed by a q&a session, if you'd like to ask questions throughout the presentation please do so by the bottom q&a button at the bottom of your screen. This can be done with or without giving your name, please note this session is being recorded and if you would like to book a consultation or find out more information, we have Karen who will be on the line at the end of the session to talk you through anything you require. I will now hand over to Mr Neen and you'll hear from me again shortly, thank you.

Mr Daniel Neen

Good evening, everybody. Thank you very much, Louise. My name is Daniel Neen, I’m a Consultant Orthopaedic Surgeon working at Benenden Hospital and thank you for asking me to talk about shoulder pains and in particular shoulder arthritis and joint replacement. So, a little bit about myself first, I graduated from London back in 1999 and have gone through my training in surgery mostly in the South-East of England in Kent mostly in fact and went off to do some fellowship training which is further sub-specialty training in Exeter and New Zealand before becoming a consultant at Dartford in 2015. The following year I started working at Benenden and have been performing reverse shoulder replacements and anatomic replacements which we'll come on to later on. Since that time really it was part of my specialty training, I performed something like 20 to 30 shoulder placements a year and so far, this year I performed 14 and, on average, the average shoulder surgeon from our national joint registry is performing about 10. Next please.

So, during the session I will attempt to show everybody a little bit of the anatomy of the shoulder and all the different things that can cause pain in the area. We'll talk a little bit more specifically about shoulder replacements and in particular reverse polarity shoulder replacements that not many people have heard about I’ll go on to talk about equinox which is the particular shoulder replacement that I use and what to expect when you have the operation itself we also have a little section from a physiotherapist regarding how they treat shoulder pain. Next please.

Right, so talking about shoulder pain, it's actually a fairly common complaint with about 14% of people in the country at any one-time having shoulder pain. They say annual incidents of about one to two percent of people so that's one or two people per 100 that will go to their gp with a new type of shoulder pain and most of them are. Nearly, or just over two-thirds are all to do with subacromial pain coming from the tendons that attach, we'll talk about that in the next section. Next please.

So, we started off with the anatomy and what a lot of people obviously have a fair idea about is the skeleton and the bones involved. We talk about the humeral head, which is the ball for the ball and socket, the shoulder blade that we call the scapula, and the socket is part of the scapula or shoulder blade. You then have a little ledge of bone over the top of the shoulder called the acromion, which is part of the shoulder blade itself and coming to meet this area at the front is your collarbone, what we call the clavicle. Next please.

Now, the ball and socket joint for the shoulder is slightly different to a hip, for example, in that the socket is far shallower it's far more like a saucer and so the analogy is like a golf ball on a tee and what this does is it allows a huge range of movement. It's the most mobile joint in the body but because of this it's not very steady and stable with regard to the bony configuration and so the stability of a shoulder really relies on the ligaments and the tendons to help matters. Next please.

So, here we have an example of a left shoulder looking at us and we have the ball and socket again and on this particular diagram we've got a couple of the tendons and ligaments starting to be drawn in and the one in particular that I’d like to show you is the liner that the tendon going across the top of the ball and socket there, which goes around the corner and then starts heading down the arm and that is one of the biceps tendons. There are two biceps’ tendons ‘bi’ meaning two and so this one attaches to the top of the socket, and this is forming a border for us that sort of delineates the top from the front of the socket itself. Next please.

So, we're adding a few more ligaments to this diagram and in particular the one at the front there stops the rotation going too far out and is involved in things such as frozen shoulder that people get, and it becomes inflamed and constricted and will stop movements all the more. There's also the one at the top which is actually a tendon and that attaches to top there to help with the movements going up when you're reaching for things at the top of a shelf for example and that is called the supraspinatus tendon and is usually involved with these tears that people develop with time or with trauma. Next please.

So, on top of all these ligaments and tendons, we've got the muscles that actually attach to the areas and there are there's one in particular the front that we call the subscapularis, the one at the top that we mentioned which is the supraspinatus and there are two at the back called the infraspinatus and the teres minor. They help to rotate the shoulder and as they work in unison together, with these pairings we call it the rotator cuff so there's rotating the shoulder and on top of all these muscles and tendons are the deltoid muscle and that's the muscle that you can actually feel on the outside of your shoulder. Next please.

So, with all these balancing tendons and muscles, they work in unison to balance that golf ball on the golf tee and, if one is damaged or torn, they don't work so well and there will be an abnormal pull one way or the other and that can affect the movements of the joint in particular and can cause pain as well at the same time and as I said the most common one is the supraspinatus, we call it the one at the top or the tendon at the top. Next please.

So, concentrating a bit more on shoulder arthritis, just like other joints the hip and the knee, we do shoulder replacements and they come in various forms. This one that we're showing now on the right side of the screen is called an anatomic, we call it an anatomic replacement because we are replacing like for like. We're replacing a ball side of things with another smooth surface and the socket with a sort of saucer-like surface and the idea is to try and replace the painful joint surfaces, we do this particular joint replacement if the tendons are all working well and in unison otherwise it becomes imbalanced and causes more issues than it solves. Next please.

This is a reverse shoulder replacement, and we usually do this when the rotator cuff itself is damaged so that the tendons have torn off or damaged and not working properly and the idea is basically to reverse the anatomy so that the socket becomes a ball and the ball becomes a socket and what you can't see on the x-ray is that there is a bit of plastic in between the two bits of metal that helps the movement of the joint to be smooth and pain-free. You can see with the x-ray on the right-hand side there that what's happened with this case is that because the tendon tore off this ball for the ball and socket it was allowed to ride up right underneath that ledge of bone that we call the acromion and start rubbing under surface there. So, with the reverse shoulder, it holds the arm down underneath the ball and doesn't allow that to happen. Next please.

We call that riding up of the ball underneath that ledge bone a rotator cuff arthropathy and it was a term coined by the gentleman in the picture on the screen there. Charles who's a very famous American shoulder surgeon and he described this migration of the human head up underneath that ledge causing more and more damage as it goes and restriction of movement along with the severe pain. He described a near complete loss of function but fortunately with a reverse shoulder replacement you can retain a certain degree of movements, it does depend on how stiff the shoulder is to begin with, but we certainly expect to try and help get the hand behind the head or reaching forwards towards at least shoulder height. Next please.

The whole idea of this reverse shoulder is quite ingenious it was brought up by this gentleman here, Mr grammar, and he started experimenting really in the 80s but the replacement itself has come on and on over the last few decades and we're on to the fourth generation of replacement already. The idea being that we place the centre of rotation in a different position, we shift the arm bone underneath the ball, and we tension that big muscle that you feel which is still intact to give it more ability to do the movements that we want your arm to do. Next please.

So, this is a particular implant that I use it's the equinox system by a company called exact tech. There are lots of different systems out there, lots of different companies and if you can imagine they're very much like car brands, they all do the same sort of thing they just little tips and tricks that they each use which they think gives it an advantage. With the equinox system, it's a platform system and what that means is that basically the stem inserts into the bone of the arm are the same for whichever type of replacement you're doing, this gives the advantage that if we start off with an anatomic replacement i.e., the ball and socket are the same way round as they should be. Should the tendons fail later, we can just replace one portion of the joint replacement rather than everything altogether. As you can see, there are different variations of the replacement, but they’re all trying to do the same thing. They're replacing that painful joint surface with metal and plastic so that you retain a degree of movement but avoid all the pain. Next please.

So, what happens when you have a joint replacement surgery? So, usually you will come in on the day of the operation itself and if it's in the morning, you'll come in the very early morning, or if it's in the afternoon, you'll come in the late morning and that's so the nurses can all do their paperwork and make sure that you're fit enough and ready for the operation itself. It will then also be seen by the anaesthetist and by the operating surgeon themselves just to go through any final details or points or questions that you may have about the operation itself. The operation is performed under a general anaesthetic and that means you're asleep for it, but the anaesthetist will normally perform a nerve block which is an injection in your neck to numb your arm up and the advantage of that is that you wake up without any pain afterwards.

The nerve block itself will usually last for about 24 hours and you should start taking painkillers before it wears off. People tend to stay one night in hospital only with a shoulder replacement as compared to hips and knees which may be a bit longer. Next please.

We get asked a lot about normal activities and, as I alluded to earlier, it does depend a little bit on how stiff and how long the arthritis has been present in your arm. So, if you've lost a lot of the muscle, you'll obviously take a little bit longer to get back to normal movements because the muscle needs to build up strength again and if your arm is stiffer or particularly stiff then the movements themselves will be slightly more restricted to start off with. In general, with the pre-operative rehabilitation, we aim to get passive movements and by that, I mean moving the arm using the other arm or with some other means other than the muscles of the arm itself by about week six and for the active movements to be at least as good as before the operation by the three-month stage. This means that in general you'll be looking to start driving from about the sixth week, if you feel confident enough to do so, golf from about three months, swimming from about three months as well lifting things. Initially you can start lifting light weights with no problem at all however you should avoid having heavy lifting for about the first six months until the ligaments tendons have all grown strong enough that they can support that activity. Next please.

As I said, it's not a new thing shoulder replacement, this is something called the National Joint Registry, which can be found on the internet and it's something that the UK have been putting together for a long time. This is the 18th annual report now and it gathers details of everybody that has a joint replacement in the country that gives consent to have their details recorded and for shoulders we've been recording the information about outcomes since 2012.

Here's an idea of some of the numbers that they've been recording over the years and obviously with the last couple of years with COVID-19 affecting the number of replacements and operations in general that we could perform and the numbers were diminished, but you can see leading up to COVID that the shoulder replacements were in the 7,000s, whereas hips and knees are going all the way up to 100,000 or beyond. So, we do far more hips and knees in this country because it's a very established operation, ankles and elbow replacements are both joints that we can replace and have started to be recorded on this National Joint Registry and it's something that will be developed over the coming years, I’m sure. Next please.

One interesting fact that's come out of these reports are the proportion of different types of shoulder replacement that we use. So, back in 2012 when they first started recording the use of shoulder replacements, about a third of them were these hemiarthroplasties and the hemiarthroplasties are where you replace one half of the joints, only you leave the socket side alone. About 25% of them were a total shoulder replacement and that's an anatomic and about another quarter of them were these reverse polarity shell replacements. But, if we look at the more recent years, there's been a bit of a turnaround with hemiarthroplasties diminishing in numbers because we recognized that replacing the socket side of things actually gave a more reliable better longer-term outcome. But the reverse polarity replacements have really taken off and nearly approaching two-thirds of the replacements that go in these days are now reverse polarity. Next.

One advantage obviously with all these new technological aspects are the aids to surgery that we now have, and the equinox system is no exception with that. So, we can use something called gps Global Positioning System, what that means is that I can take a scan before the operation of your shoulder and then plan where I’m planning to put the socket. The angles are all worked out and it sizes it for me as well, so I can go into an operation with a very clear idea of where I want to put the prosthesis itself and any potential pitfalls, such as little bony protuberances which may throw me off otherwise. The other thing is that we can take it one step further even and use this special machine that will guide the drill so that I know exactly where I’m drilling, what angle I’m drilling and place any screws within the bone rather than guessing where I’m putting them. This leads to more predictable surgery and the thought is that, in the longer term, it will give us a better outcome. But that is yet to be proven. Next please.

Obviously, we've talked about arthritis as a cause of shoulder pain, but there are many more causes for shoulder pain given how many structures attached and involved in the shoulder itself. As we talked about the rotator cuff, if there is a torn tendon for example it may be more suitable that we repair the tendon rather than going to try and do something with the joint itself. Frozen shoulder was one of the things we mentioned with the tightening and inflammation of the ligament at the front of the shoulder, but the whole joint itself can become very inflamed and cause diminished movement and severe pain and along with injections a release can be performed to help range of movement. A subacromial decompression is an operation where we shave a little bit of the bone on the under surface of that ledge of bone that we talked about called the acromion and the idea is to increase the room for the tendons to move to stop them infringing on the underlying tendon itself and causing more damage. Obviously, physiotherapy is the mainstay of treatment initially and we have a physiotherapist who can give us more information about that online with us today.

Jordan Dehara

There are many reasons you can suffer with shoulder pain, and we tend to separate them into traumatic or degenerative. The traumatic reasons could be if you've injured your shoulder playing sports, or it could be at work. The degenerative reasons could be that you're you've got an underlying weakness or the joints a bit stiff, or you have imbalances somewhere else in the body, so it could be neck or coming from your back.

Exercises and keeping active can help manage shoulder pain because it keeps your joints supple, and it keeps your muscles strong. The shoulder joint requires a lot of strength to stabilize the joint, so it's really important to stay active and lead a healthy lifestyle.

You would want to seek help for your shoulder pain if the symptoms appear to be getting worse after two weeks because this is the period where structures become inflamed and it takes two weeks for them to kind of settle back down through just self-management techniques, such as taking pain relief, anti-inflammatories and putting ice on the area and just generally trying to not aggravate the shoulder. Otherwise, if the shoulder pains been going on for six weeks, then it would be beneficial to seek help from your gp, physiotherapist or consultant and for them to give you professional advice on how to manage the pain.

At your first physiotherapy appointment, you'll have an initial assessment of an hour where we would assess the problem and give you an idea of what's going on and how we're going to manage it. We then treat you for as long as you need to get back to your goals and that could be hanging up the washing, which could be playing sports. Once you've achieved your goals, we will tell you how to manage it from then on and prevent it from coming back in the future.

If conservative management hasn't helped in physiotherapy, then we tend to refer the patient onto the consultant for further investigations and to for surgical opinion.

Louise King

Thank you, that was very interesting. We're now going to a q&a session and please do feel free to send over any questions you have no matter how small they might be.

The first question, they say they've been suffering for quite some time with arthritis, their doctor has previously mentioned shoulder replacement surgery, but they feel that is a last resort and should they wait until it's unbearable? Are there risks to not having surgery and putting it off for longer?

Mr Daniel Neen

That's a that's a good question, so the whole point of shoulder surgery for replacing the joint is to help quality of life. If pain is affecting your daily activities despite taking painkillers on a regular basis, stopping you doing things the things that you want to do and keeping you awake at night because night pain can be particularly severe, then it's worthwhile talking through the risks of the operation. All operations have risks, the overall risks with joint replacements are known and documented and with a reverse shoulder replacement for example, they think the cumulative risk is six percent to 94 percent of the time there are no problems at all. Now that six percent covers a wide range of things from something very minor to something more serious, but obviously we must balance how badly the pain is affecting the quality of your life versus whether it's worth taking the risk. People say it's a last resort and that's an interesting thing, I think you should certainly try all other interventions that are less risky first and then yeah absolutely, seeing a consultant with regards to talking through whether you benefit from the shoulder replacement would be worthwhile.

Louise King

Okay, thank you. Okay, our next question, this person is looking at having a shoulder surgery as they've been suffering from shoulder pain for years. It stopped them from being as active as they used to be and they'd love to get back into tennis, would it be too intense to play tennis afterwards?

Mr Daniel Neen

So, there are various forms of surgery that we can do for the shoulder, so it does depend a little bit on what diagnosis we're treating here. In general, if you're talking about a shoulder replacement then no, I think once the healing stage is over, and the tendons are strengthening up and the muscles and the control of the shoulder is strengthening up, then going back to something like tennis is entirely feasible. I wouldn't necessarily go back to it straight away and you are talking about many months of rehabilitation first. If the range of movement is acceptable for the use of a tennis racket, which I’m sure it should be, then going back to tennis will be okay.

Louise King

Thank you. Okay, this person is 62, they have seen the doctor and a physiotherapist many times with shoulder pain. They're worried about having a replacement, how long would it last for and would they need to have surgery again?

Mr Daniel Neen

Yes, so the one worry with the shoulder replacements is longevity and the good news is that the latest information that we have from different research data that comes in left, right and centre from different countries, not just our own, does look like these shoulder replacements last a good length of time. You're talking about 95 percent lasting more than 15 years; they do wear out unlike a body where you can heal. If there's a little bit of damage with a false joint, that damage potentially can accumulate the things that hold the joint in place and can loosen up. You can get more wear and tear changes, so with somebody with an anatomic replacement at the age of 60 there's a good chance in fact that you may have to have a further operation into your 70s late 70s. Where you are replacing the shoulder placement itself with a new implant, a second revision surgery now whether that's an another anatomic or a reverse shoulder does depend a little bit on the state of the tendons at the time but it's entirely possible.

Louise King

Okay, thank you. Next question, this person is 54 and they have a torn rotator cuff, if they had this treated, would the recovery be like a shoulder replacement?

Mr Daniel Neen

Okay, so slightly different recovery time but a similar process in that you're still waiting for these tendons to heal back in place. The idea of a tendon repair is you are basically pulling the tendon which is pulled off from the bone and can't get back down to the bone itself, without a little help you pull it back into place and hold it in place with some material which is actually made of a plastic that holds it in place but is not strong enough to take the full weight of and forces required for everyday activities. So, we do tend to protect the repair while that process is ongoing and the biology is about three months for that to form strong enough bonds that you can start putting force through it, so usually for the first six weeks or so you're in a sling and then thereafter we start getting increasing movements and then strengthening exercises in a gradual manner.

Louise King

Last few questions now. This person has damaged cartilage within their shoulder joint, and they suffer badly with shoulder pain. They believe this would be keyhole surgery instead of full replacement, therefore would they need to stay overnight in hospital?

Mr Daniel Neen

Right, so it sounds like they're going to be having something called an arthroscopy, which is the keyhole surgery debridement, which basically means clean-up of the joint. We tend to reserve that sort of operation for people who have arthritis damage to the joint surface, it is a form of arthritis, and it depends on how large the surface area affected. But, if we don't want to go down the root of a joint replacement, either because the area is very small or they're very young for the operation, then we tend to do this debridement stage. The keyhole surgery itself is usually a day case procedure absolutely and so you wouldn't necessarily have to stay in hospital. The joint replacement itself can't be done through keyhole, unfortunately it does require a little bit of a bigger incision usually around 10 centimetres or so at the front of the shoulder.

Louise King

Thank you, this person they say, I have needed to have a shoulder replacement for a couple of years, but I’ve put this off as I’m approaching 80 and so I’m worried about having major surgery. Is age a concern for having this type of surgery and can it affect my recovery?

Mr Daniel Neen

So, our prime candidates for a reverse shoulder tend to be in their 70s and so any operation is a concern and obviously with age come co-morbidities as we call them, which means other medical issues potentially with hearts or lungs or kidneys. We do have to take that into consideration when we're planning any major operation and a joint replacement is a major operation, however anaesthetists are very aware of all these potential problems from a surgical point of view. The operation is the same regardless, we must be a little bit careful if we think that the bones are going to be a little bit more fragile, but in general the operation technique is going to be the same regardless of age. What I would say is if the co-morbidities go from an anaesthetic point of view, we do have to be a little bit more careful definitely with age and the anaesthetists we use are very careful in explaining to the patient the risks and whether they think that the anaesthetic is a good idea or not and we'd be upfront with that. We wouldn't necessarily anaesthetise everybody that needs an operation.

Louise King

Thank you. This attendee is 56 they've had shoulder pains since they started working from home in 2020, their gp and physio gave them some online showdown exercises, but they did not help. The pain is less now but they still can't raise their arm above their head. Is there anything more that can be done without going down the surgery route?

Mr Daniel Neen

Thank you, so we saw a huge wave of people coming in with shoulder pain and started working from home and I think it was something to do with how people were working, on their laptops in front of them rather than on the work assessed workstations that you have in the offices. A lot of shoulder pain is to do with position and posture that you take, which is why physiotherapy is such a good way of treating shoulder pain in the initial stages. So, if you imagine that you're hunched over a desk or your laptop, your shoulders are rounded forwards and when you're doing that, you're actually diminishing the space between that ledge of bone that you can feel on the outside and the underlying tendons and that causes a physical pinching we call impingement. People are far more likely to develop the sort of secondary effects of this position such as tendonitis, inflammation of the tendons, inflammation of the cushion that surrounds that area and so the other problem obviously is that with shoulders it takes a long time for things to calm down and it's not unusual for shoulder pain to take a good 9 to 12 months to settle down, which is why again we don't leap into surgery necessarily straight away when some of these things will calm down on their own without us doing anything at all. So, in terms of other things that you can do for shoulder pain, other than physiotherapy, we can try and help calm down any inflammation with an injection of a steroid, not the sort that people use to body build, the type of steroid that we use in injections is a very strong anti-inflammatory, the pills that we take ibuprofen, naproxen they're called non-steroidal anti-inflammatories, but the injections we use are steroidal anti-inflammatories and these injections they give the drug a six-week window to work in their area, specifically, where it's causing the issue. Physiotherapy, shockwave, acupuncture is all modalities’ physiotherapists can use to try and help calm down the pain without going on beyond into the more invasive interventions if you like.

Louise King

Okay, so that's all the questions we have, so thank you very much for everyone who sent in the question and thank you Mr neem for answering them so clearly. Just to highlight on the screen, we are doing 50 off your first physiotherapy appointment and 50 off an initial consultation with Mr Neen, if you book this through our Private Patient team by the fifth of August. We just need to quote the webinar on the subject line for that, Karen our Private Patient Advisor is on the line now if you want to speak to her until 8pm, she can advise you when booking for consultation with Mr Neen. Alternatively, her team are in the office 8 a.m. to 6 p.m. Monday to Friday, at the end of this webinar you'll be presented a short survey and we'd really appreciate it if you could complete, that helps guide and steer our future presentations and give feedback to our consultants. Our next webinar is in two weeks’ time on the 18th of July, with Consultant Ophthalmic Surgeon Mr Wallace Poon. He will be discussing immediate effective and safe cataract treatment and the special lenses we provide at our special eye unit in the hospital. So, on behalf of myself, Mr Neen and everyone at Benenden Hospital, I'd like to thank you very much for joining us today and we look forward to seeing you again soon at one of these events. Thank you, bye.