Shoulder Arthritis: Diagnosis, Treatment, and Living a Pain-Free Life with Dr. Amit Sood

If shoulder arthritis has been causing you pain, this episode is your gateway to a pain-free life. Today, we learn from the best in the field, Dr Amit Sood, Chief of the Shoulder Service at Kayal Orthopaedic Center. Dr. Sood takes us on a journey through the intricate world of shoulder arthritis. He gives us a glimpse into how he diagnoses and manages this debilitating condition, elucidating on the anatomy of the shoulder joint. 

We discuss not only the common symptoms and causes but also the various treatment options available. Dr. Sood shares his insights on the advancements in shoulder replacement surgery, with a detailed explanation of the pre-operative block and the benefits of outpatient procedures. His expertise on the precise placement of implants and the importance of preserving bone for potential revision surgeries is truly enlightening.

But what comes after the surgery? Dr. Sood emphasizes how we can live a full life post-shoulder replacement. By engaging in activities mindfully, we can ensure the longevity of the shoulder replacement and enjoy life to the fullest. Just like caring for a prized car, we need to treat our shoulder with care to enhance the quality of life. So, join us as we delve into the world of shoulder arthritis and its management, and equip ourselves with the knowledge to live a pain-free life.

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Episode Transcript

Speaker 1 (00:00):
Hello and welcome to another edition of the Kaila
Ortho podcast.
Today is July 6, 2023, andwe're very excited to have with
us today Dr Amit Sud.
Dr Amit Sud is the chief of theshoulder service at the Kaila
Orthopedic Center and he's beenwith us here at Kaila Ortho for
about eight years now.
Welcome to the podcast, dr Sud.

(00:20):
Thank you for having me.
Dr Kail, we're so happy to havehim with us today.
Dr Sud is a highly trained andexperienced shoulder expert in
the field of shoulder surgery.
Why don't you tell us a littlebit about yourself, dr Sud, and
your training as well?

Speaker 2 (00:34):
Sure, i actually grew up in the Chicagoland area and
I went to the University ofIllinois in Urbana-Champaign
where I did my undergraduatetraining and, following
graduation, i did my medicalschool training at the Medical
College of Wisconsin andfollowing that, i eventually
made my way to the east coast,to New Jersey, where I did my
orthopedic surgery residencytraining at what was called

(00:56):
UMD&J before, which is calledRuckers Now, where I did
extensive orthopedic surgerytraining.
Following that, i did aspecialized fellowship in
shoulder and elbow at theHarvard Boston Shoulder
Institute program, where I spenta year training with highly
skilled surgeons in the Bostonarea, learning about more
advanced techniques in shoulderand elbow surgery.

(01:18):
Part of that fellowshipinvolved traveling to France, in
Europe, where I spent timetraining with some of the master
surgeons in Europe as well,learning a lot of the techniques
that they helped to enhance forsurgeons throughout the world.
I spent some time training inNice, france, with Dr Pascal

(01:39):
Wallo.
I spent some time in Honesty,france, with Dr Laurent LaFos,
learning very advancedarthroscopic techniques, and I
also spent time with what'sconsidered one of the
grandfathers of orthopedicshoulder surgery, which is Dr
Gilles Valls, in Lyon, france,as well, and it was truly a
tremendous opportunity that notmany orthopedists get to do.

(02:03):
Usually you have to take timeout of your own practice, once
you've gone outside yourfellowship, to go and travel and
follow different surgeonsthroughout other parts of the
world to learn advancedtechniques.
And I was fortunate enough,where it was a part of my
fellowship, it was integratedinto the program where I
traveled there, lived there withthe folks in the community,

(02:23):
trained with the surgeons at thehospitals, both seeing patients
and in the operating room, andreally got to know them on a
more personal level, where itwasn't just going to work with
them, it was eating dinner withtheir family, going out, talking
, having laughs and reallygetting to immerse myself in the
culture.
And it was an opportunity thatI can't replace and I'll cherish

(02:45):
that forever.
Following that fellowship, iwas fortunate enough to come
back to New Jersey.
I actually met my wife while Idid my residency in New Jersey
and she always tells me once aJersey girl, always a Jersey
girl.
So she wanted to come back toNew Jersey and I was fortunate
enough to come to the KaleOrthopedic Center, where I've
been ever since and I've lovedit.

Speaker 1 (03:07):
It's no wonder we love your wife so much.
I mean, what an experience totrain in that part of the world,
especially with those expert,expert shoulder surgeons, and
certainly you've gone so mucheducation and skill and
expertise over the years that wetruly consider you very much an
expert shoulder surgeon, drSood, and you've taken care of

(03:30):
thousands and thousands ofpatients for us at Kale
Orthopedic Center over the lasteight to 10 years and we're just
so privileged and blessed tohave you, thank you.
Today's topic is going to be onone of the more common shoulder
conditions called shoulderarthritis.
We are going to be discussingwith Dr Sood today the
evaluation and management ofshoulder arthritis.
We're going to diagnose it.

(03:51):
We're going to see how heevaluates patients presenting
with shoulder arthritis, whatsigns and symptoms he
appreciates when he hasencounters with them.
We will be discussing theconservative, nonoperative and
surgical management of shoulderarthritis as well.
So let's just dive right in andlet's talk about a little bit

(04:11):
of the shoulder anatomy so wecan define the anatomy and then
we can start defining thecondition as well.
Okay, sure.

Speaker 2 (04:18):
So the shoulder joint is comprised of the humeral
head as well as a glenoid bone,and the glenoid bone is a part
of the larger bone in the backof the shoulder, which is the
scapula bone, and the humeralhead is a part of the upper part
of the arm or the upper part ofthe humerus, and it articulates
with the glenoid.
And my analogy for the shoulderjoint is comparable to thinking

(04:40):
about a golf ball and a golftee, and so you look at the golf
ball as being the.
The humeral head is a golf balland the glenoid is the golf tee
, and, as you can imagine, it'sa very unstable joint.
In fact, the shoulder joint isthe joint with the most range of
motion in the entire body ofall the joints, and so you can
imagine what the golf ball isseeing on a golf tee is very

(05:02):
unstable.
You could just flick the golfball and it could fall right off
.
And the shoulder if you watchenough sports, you hear about
shoulder dislocations all thetime.
So it's one of the mostcommonly dislocated joints.
So it's very unstable, and sothere's a big interplay between
the muscles, tendons, as well asthe bones to keep that shoulder
stable.
And because it's so unstable.

(05:25):
It doesn't just rely on thebony anatomy for stability.
There's a ring of tissue aroundthe glenoid called the labrum,
which provides stability for theshoulder joint.
There's also capsular tissueThink of it like a balloon
surrounding the shoulder jointthat helps keep it stable as
well.
And there's a variety ofdifferent muscles and tendons,
the most important being therotator cuff muscles, which is
comprised of four major musclesthe sub scapulae, super spinaeus

(05:48):
, infraspinaeus and teres minor,which help to keep the shoulder
stable as well and providerange of motion for the shoulder
joint.

Speaker 1 (05:55):
Yeah, so we talk about the dynamic and static
stabilizers, right?
So the muscles primarily makeup the dynamic stabilizers to
stabilize that construct.
And then there are the staticstabilizers the bone, the
ligaments, the capsule, thelabrum, things like that.
I use the same analogy of thebone socket joint and the golf
ball sitting on the tee.

(06:15):
It's an inherently unstable,but if it weren't for those
dynamic stabilizers to stabilizethat joint, it would very
easily dislocate or definitelysublux.
So that's the anatomy of theshoulder joint.
So, as far as arthritis isconcerned, can you define that
condition for our audience?

Speaker 2 (06:37):
Yes, There are different kinds of arthritis,
the most common being standardprimary osteoarthritis, or wear
and tear arthritis as mostpatients call it.
And on the surface of thehumeral head as well as the
surface of the glenoid bone,which are the two bones that I
mentioned earlier, there's asofter, more smooth coating on
those bones, which is thearticular cartilage.

(06:59):
So you can imagine or you knowthat the bone is a very hard and
rough structure And so youdon't want bone contact the bone
.
And so in every joint in thebody we've evolved to have this
articular cartilage at the endsof the bones to provide a more
smooth surface of where they cantouch and meet each other.
And normal wear and tear orprimary osteoarthritis involves
the degradation or erosion ofthe articular cartilage, And

(07:21):
what happens is, over time, youstart to thin out on that
cartilage And as it starts tothin out more and more it
exposes the bone that's lyingunderneath and that's what's
termed the bone on bonearthritis.
So as you start to expose thebone you could imagine bone
touching bone and it starts togrind and cause pain over time,
and especially if it's involvedon both sides of the joint or

(07:42):
both bones that are part of thatjoint, the pain can be much
worse.

Speaker 1 (07:47):
Yeah, and you know, arthritis, as we've defined in
the past, is inflammation of thejoint and, just like the other
joints that we've discussed inthe past, it's often associated
with redness, warmth, pain andswelling in that joint.
And of all the arthriticconditions in the body, for some
reason shoulder arthritis seemsto be the most debilitating,

(08:07):
right for the most part.
These patients really complainoften of inability to sleep at
night, and it definitely affectstheir quality of life, because
all of us need to sleep and geta good night's sleep and, for
whatever reason, when patientshave shoulder disorders, very
often they can't sleep at night,right.

Speaker 2 (08:26):
Absolutely.
That's probably one of thebiggest complaints that I get.
Initially it starts out ashaving this sort of dull, too
thick type pain that patientscomplain about and it can happen
spontaneously and over time asthe arthritis advances it could
happen even at rest and againthat sleeping situation where
you're not even using it atnight, you're just laying there

(08:46):
and it can cause pain.
But that's one of the mostcommon presenting complaints.
In addition to being unable tomove the arm or use it for even
basic functional activities likeputting food up to your mouth
to eat or brushing your hair orbrushing your teeth or reaching
into a cabinet, over time youget this functional limitation
and pain associated with justdoing basic household chores.

(09:10):
The other thing is, as thearthritis advances you can also
develop what's called a crepitusor clicking and popping of the
shoulder and that really happensas you're road more and more
cartilage over time and get thatbone exposure and that can be
very debilitating for patientsand oftentimes it could be an
audible click or snap that youcan hear even examining patients
in the office.
And then, as time goes on,again the night pain is

(09:33):
something that, again, not evenusing it, you're laying down
going at night and patientscomplain that they can't sleep
at night and to me that's themore worrisome symptom because
if they can't sleep at night itaffects them the next day.
They don't have the same energylevel, mentally they don't feel
the same, at least depression,anxiety, etc.
So once you start losing sleepwe know that it's a more serious
problem.

Speaker 1 (09:53):
Arthritis can obviously lead to pain in the
shoulder, especially at night,some loss of motion as well,
because you lose that nicearticular cartilage and the
joint starts to erode.
But how do you know it'sarthritis that's causing that?
Can it be other things in theshoulder It?

Speaker 2 (10:10):
can be a variety of different things, like we
mentioned on the anatomy, thesoft tissue structures that are
in the shoulder.
So it can be pain can be causednot just by the bones but by
those soft tissue structures.
So you can have labral tearsthat can occur as well as
rotator cuff tears or ligamenttears that can happen in the
shoulder.
So it's important when thepatient comes to the office that
we do a thorough examination tofigure out what exactly the

(10:32):
problem is.

Speaker 1 (10:32):
Yeah, so it makes a difference, right, if a patient
comes in, because patients withthose conditions that you
mentioned rotator cuff tears,labral tears and other disorders
of the shoulder can also havenight pain, right?
So how do you distinguish inthe office, based on physical
examination and imaging, todetermine what in fact is wrong
with the patient, if it's trulyarthritis or if it's a rotator

(10:54):
cuff tear, a labral tear, aproblem with their biceps tendon
or all of the above?

Speaker 2 (10:59):
It initially starts out with a good history.
I think just by talking to thepatient you can learn a lot
about what the problem really is, and so it's important to, as a
physician, talk to the patient,hear what they're saying and
process that.
There's a lot of differentfactors to consider.
Was it traumatic?
Were they skiing downhill andall of a sudden they fell?
Were they're playing basketballand fell?

(11:19):
or riding a bike and fell andlanded onto the shoulder and
then developed pain In thatsituation?
if they didn't have pain before, i'm less likely to think that
arthritis is a problem, andmaybe they disrupted one of the
soft tissue structures that wetalked about with the shoulder.
If they fell and dislocatedtheir shoulder and went to the
emergency room and one of thedoctors had to put it back in
place, depending upon the age ofthe patient younger patients it

(11:41):
tends to be associated withlabral tears.
As a patient gets older, whenyou dislocate your shoulder, we
tend to see rotator cuff tearsas a more common associated
pathology.
So all these things I have totake into consideration when I
talk to the patient.
In addition, we always takex-rays when the patient comes to
the office.
I get more concerned aboutarthritis as the patients are a

(12:02):
little bit on the older side butagain we're seeing it more and
more at a younger age as well,with this post-traumatic
arthritis that can develop.
So we take x-rays in the officeand we evaluate the bony
architecture and we look at theball in the socket or the golf
ball in the golf tee that wementioned earlier and we see is
there a space between the twobones?
and it?
has there been degradation ofthe cartilage that's on there?

(12:22):
One thing that we see if thereis degradation of the cartilage
is that the bones start to movetogether.
So you see the humeral headtouching the glenoid bone and
oftentimes, as the arthritisadvances, not only do the bones
touch together but we see otherfindings on the x-ray as well,
for example development ofosteophytes or extra bone
formation on the x-rays as well.
And the body does that inresponse to the stress that

(12:45):
develops across the jointbecause of the loss of the
cartilage.
And so the body responds bytrying to grow this extra bone
and distribute the stress acrossa greater surface area, not
knowing that it's actuallycausing more of a problem for
the patients and that couldinhibit the range of motion and
cause clicking or popping.
And once I hear the patientcomplaining of clicking or
popping in the office, i knowthat either it's unstable,

(13:07):
either it's shifting in and outof the joint or potentially
these osteophytes causing thatnoise, and so we're able to pick
that up on the x-rays.
In addition to listening to thepatient, we also do an
appropriate physical exam.
I will start by touching thepatient both over the biceps
tendon as well as theacromioclavicular joint.

(13:28):
Those are some common areaswhere we see associated pains.
We want to rule that out as asource of pathology.
We also test range of motion,and we test both active range of
motion as well as passive rangeof motion.
And by checking the passiverange of motion I'm able to see
if the patient is either stiffor just unable to move the
shoulder.
So if they can't lift up theirshoulder but I could lift it up

(13:49):
for them I know that they're notstiff.
That's just a lack of range ofmotion secondary to either pain
that they're having or thatmaybe they tore their rotator
cuff and can't physicallyelevate the shoulder.
If my passive range of motionis similar to the active range
of motion, then I'm moreconcerned about stiffness, and
that's a whole different varietyof conditions I can develop,
for example, frozen shoulderthat you can develop and cause

(14:11):
stiffness in the shoulder.
So we do a thorough physicalexam.
We also do strength testing.
So we test a different rotatorcuff muscles and tendons that
are on the shoulder And the fourdifferent rotator cuff muscles
that I mentioned earlier thesubscapularis, which is on the
front part of your shoulder.
When that contracts it resultsin internal rotation.
So we're always testinginternal rotation strength to
test that specific rotator cuffmuscle.

(14:33):
I also check for forwardelevation strength, which is for
the supraspinatus rotator cufftendon, as well as external
rotation, which is for theinfraspinatus rotator cuff
tendon and the teres minorrotator cuff tendon.
So, based on strength testingthat tells me the integrity of
the rotator cuff tendons andgives me information.
I also check for instability ofthe shoulder to see if the

(14:53):
shoulder wants to slide out thefront or the back of the
shoulder and even if it doesn'tslide, if any provocative
maneuvers cause pain in thosedirections which leads me to
potentially having a labralpathology in that shoulder.
I also raise their arm andcheck for signs of any
impingement or bursitis byraising the arm and internally
rotating the arm to see ifthere's any symptoms of

(15:14):
impingement Right.

Speaker 1 (15:15):
Well, i think all of this is very, very important,
but probably the most importantthing that you identify is
whether or not the patient hasarthritis.
because there are a lot of softtissue problems that you see on
a daily basis in treat labraltears, biceps, tendon injuries,
rotator cuff tears.
But I think the game changingfinding is when you identify

(15:39):
that there is arthritis thatexists in addition to all those
things, because as soon as weidentify that arthritis exists
in that joint, it changes ourconversations with our patients
Right.
So if it's an isolated softtissue problem so for instance
then in the knee, if there's ameniscus tear or an ACL tear

(16:02):
typically we'll address thatsoft tissue problem
arthroscopically in a sportsmedicine type procedure.
Once we identify that arthritisis also present on the X-ray or
MRI, it changes ourconversations with our patients.
It's important for the patientsto understand that we don't
just treat those soft tissueproblems when there's arthritis.

(16:25):
we have to do something bigger,more definitive, where we take
care of the arthritis as well asthe soft tissues at the same
time.
Why don't we just inform ourpatients how you would address
somebody that presented witharthritis in the shoulder?
What is the first line oftreatment for those?

Speaker 2 (16:40):
patients.
We always try and start with aconservative management for the
patient.
When the patient first comes inand we identify that they do
have arthritis, we want somepain relief and that's usually
the first presenting complaintthat they come with.
And, as you mentioned earlier,osteoarthritis is inflammation
of the joint and pain relief isdesigned towards decreasing that
inflammation.
So if there's not any medicalcontraindication, we recommend

(17:04):
oral anti-inflammatories toreduce the inflammation and help
with the pain and hopefullyhelp with some of the night pain
that some of them might beexperiencing or pain with daily
activities.
Also, we always recommend somephysical therapy for the patient
.
Oftentimes they're limited witha range of motion or have an
element of weakness, and we wantthe physical therapists to work
with them to optimize the rangeof motion as much as they can

(17:26):
and also decrease the pain asmuch as they can.
The goal of physical therapy isto help stabilize the shoulder.
Because they're bone-on-bone atthat point or have eroded a lot
of their cartilage.
Even any element of microinstability can cause pain
across the shoulder joint.
So what we want to do is getthem into physical therapy,
strengthen the rotator cuffmuscles and also in turn, that

(17:47):
provides stability for theshoulder and decreases that
micro motion and can helpdecrease the pain for the
patient.
We also try, if the patientchooses to do so, cortisol
injections which can beadministered both in the joint
as well as outside the joint tohelp with bursitis.
I usually will do a combinationof both.
If I feel like there's a lot ofimpingement related pain or

(18:09):
bursal sided pain, i will do asubacromial space cortisol
injection in the office.
If a lot of the pain is beingderived from within the joint
itself, where the arthritis is,i will do a cortisol injection
into the glen and hemorrhagejoint where that articulation is
.
It's very important to beprecise with that injection and
oftentimes it can be difficultto do In the office.

(18:30):
I will do it under fluoroscopicguidance to make sure that I
have it in the correct locationso that when the patient gets
the medication they get the mostrelief from that injection.

Speaker 1 (18:39):
Yeah, i think it's important for patients to
understand there are differentareas that we inject in and
around the shoulder.
It's important to identify ifthe problem lies within the
bowel and socket joint, thatyour doctor injects the bowel
and socket joint as opposed tothe area above the bowel and

(19:00):
socket joint.
For instance, a lot of patientspresent with night pain from
rotator cuff pathology or acondition like bursitis or
impingement that Dr Seud wasreferring to.
Those injections typicallywould take place outside of the
shoulder joint and thoseinjections are typically given
from the side or the back of thepatient to that area where the

(19:22):
bursa is.
But when patients have shoulderarthritis or problems inside
the shoulder, like labral tearsor long head of the biceps
tendon injuries, thoseinjections have to be performed
inside the joint and it'sdifficult to inject the shoulder
joint itself, and so at theKaila Orthopedic Center we use
imaging technology such asultrasound or fluoroscopic

(19:44):
guided technology to make surethat when we're injecting the
shoulder joint we're actuallyinside the shoulder joint,
exactly where we want to be, sothat the patients get the most
relief.
In addition to the injectionsof cortisone, are there other
types of injections that you cantreat our patients with for
shoulder arthritis?

Speaker 2 (20:03):
Yes, there's orthobiologic.
So in the office I do doplatelet-rich plasma or PRP
injections, as is commonlycalled, where we take the
patient's own blood and it's nota lot of blood, only about 15
cc's and we do it right there inthe office And we actually use
a centrifuge machine to extractthe platelets from the blood and

(20:24):
we inject that into theshoulder as another option for
pain and also another optioncompared to cortisone injections
?

Speaker 1 (20:32):
Yeah, certainly, regenerative medicine is popular
these days, and orthobiologicaltherapy utilizing autologous
conditioned plasma andplatelet-rich plasma is very
helpful in decreasing theinflammation in the joint, which
can definitely contribute withalleviating our patient's pain.
So, besides the injections inphysical therapy and

(20:54):
anti-inflammatories, are thereany surgical procedures that can
be done to help alleviate someof these patients'?

Speaker 2 (21:00):
pains.
There are arthroscopicprocedures that have been
described.
They're not designed forlong-term relief because over
time arthritis does tend toprogress.
There is a certain populationthat can benefit from it.
Sometimes we'll see youngerpatients where there's the
development of arthritis but ithasn't gotten to the point where

(21:20):
it's bone on bone or they havelarge bone spurs And, as you can
imagine, some of these youngerpatients don't want to commit to
a full shoulder replacement atthat time.
And so there are arthroscopictechniques where we go in and
basically we're cleaning up theshoulder in a way and any
inflamed tissue or loose bodiesthat might exist in the shoulder
we remove that.

(21:41):
Oftentimes the capsule can bevery tight of the shoulder which
is compressing the humeral headagainst the glenoid.
So we'll do a capsule or releaseat that time where we sort of
cut around that balloon that Idescribed earlier or the capsule
and that helps to loosen it upa little bit and get the bone of
the humeral head maybe lesstension onto the glenoid.
Oftentimes with arthritisthere's also associated biceps

(22:03):
tendinitis And you can also do abiceps tinnadesis we call it at
the time of the arthroscopy,where we basically remove the
insertion of the biceps from thelabral tissue and we tack it
down into the humeral bone So wekeep it from sliding where a
lot of the irritation and theinflammation develops.
Also, if there are any smallbone spurs, we could use a burr

(22:26):
and remove those bone spurs atthe time of arthroscopy as well
to try and limit the impingementthat they can get and limited
range of motion that can developfrom having those bone spurs.
So an arthroscopic procedure isan option as a less or more
minimally invasive procedure forpatients who are appropriate
candidates if they're youngerand aren't to the point where
they can commit to a fullshoulder replacement.

Speaker 1 (22:46):
Yeah, and sometimes a lot of us that do arthroscopy
will find a patient that'srelatively young, has a
beautiful looking shoulder jointbut unfortunately suffered a
trauma and has now a big potholein the articular cartilage of
the glenohumal joint or thebalsakha joint.
And that's a difficultsituation where you have a young

(23:09):
patient, sometimes 30, 40 yearsof age, beautiful anatomy,
intact rotator cuff, biceps,labrum, everything's perfect But
there's a big pothole in theglenoid or in the humeral head.
missing cartilage and bone isexposed.
Fortunately, some of thevendors that we use offer

(23:30):
instruments that allow us to usesome procedures, like a
microfracture, where we combinethat with the regenerative
medicine that we talked about totry to regrow the cartilage and
fill the defect.

Speaker 2 (23:42):
Yes, absolutely So.
Just like a regular road thatwe drive down, if there's a
single pothole in the street,they don't replace the entire
road right.
So this happens after everywinter in New Jersey, where they
come in the spring time andfill in those potholes.
And the same concept applies tothe shoulder, where if it's
just a small little defect or apothole in the shoulder, we
don't need to replace the entireshoulder.

(24:03):
In that situation There areother options that are there.
Microfracture, as you alluded to, is one of them, and what we
want to do is essentially fillin that pothole.
So there are multiple ways todo that.
Microfracture is one techniquewhere, arthroscopically, we go
in in a very minimally invasivefashion and we make smaller
holes within the base of thatpothole, and when we're in there

(24:25):
doing the arthroscopy we'reputting a lot of fluid into the
shoulder and it prevents thebackflow of blood.
But once that fluid pressure isgone at the end of the
procedure and we actually testthis after we make the little
holes at the base of the potholewe eliminate the fluid from the
arthoscope or the camera thatwe're using during the procedure
And what you see is bleedingthat comes back in through those

(24:48):
holes And, as the patients werecovering, what happens is that
that bleeding induces theformation of scar tissue to kind
of form in within that potholeover time to fill that defect,
and so that's one technique thatwe use, which is the
microfracture technique.
There's also a newer techniqueswhere you go in and we harvest a
piece of the cartilage and takeit to a lab And that lab grows

(25:11):
these chondrocytes.
And once we grow thosechondrocytes we come back and we
implant that into the pothole.
So we put into the pothole withthe fiber and glue that holds
it in place And we're trying touse the body's own natural cells
of the cartilage to try andfill in that defect.
So not just with scar tissuebut hopefully with some
cartilage, and that's anothertechnique that we utilize as

(25:32):
well.

Speaker 1 (25:33):
Yeah, so clearly the future of orthopedics is
regenerative medicine andhealing disease, joints and
repairing structures, as opposedto replacing and reconstructing
torn structures as well.
Right, so that's an exciting upand coming field, and right now
, in 2023, i guess the best wecan do with these defects is the

(25:56):
microfracture and theprocedures that you've outlined.
But let's go to the next stagenow, where the patient's
arthritis is too advanced and isnow a candidate for something
more definitive.
The surgical procedures we'vediscussed thus far have been
mainly palliative, in effort tobuy time, because none of them

(26:18):
are really guaranteed.
Even the field of regenerativemedicine is not where it's going
to be in the future.
Still, to this day, it's notreally possible to regrow normal
articular cartilage with likethe cartilage we were born with,
and so We tend to do theseprocedures to buy time To a

(26:41):
point in in time when thepatient is more amenable to
undergo a more definitiveprocedure.

Speaker 2 (26:47):
So once the degradation of the cartilage or
the arthritis becomes moreadvanced, we do was called a
shoulder replacement or ananatomic shoulder replacement
for for primal acerothritis.
What we do is we basicallyresurface the ball part of the
Shoulder joint, which is thehumeral head, and we also
resurface the Glenoid, which isthe golf tee part of the the

(27:09):
shoulder joint.
And basically what we're doingis similar to, again, the road
analogy where If there's toomany potholes on the road You
can't just go in an individualphilic pothole.
Even if you drive across, it'sstill gonna be a very bumpy road
.
And so basically we're going inand we're surfacing the entire
surface of both parts of theshoulder joint to provide a more
smooth articulating surface.

(27:29):
And What we do for an anatomicshoulder replacement is on the
humeral head or the golf ballpart of the shoulder joint, we
use a metal sphere to Provide amore smooth surface for
articulation at least of thehumeral head component, and on
the glenoid part of the shoulderWe replace that with a plastic
component.
So basically at the end of theprocedure you have smooth metal

(27:51):
articulating with smooth plastic, and so you don't have that
bone-on-bone grinding sensationand you don't have bone spurs,
because the bone spurs arelimited at the time of surgery
As well.
So you have smooth metalarticulating with smooth plastic
and it's a very smooth range ofmotion.
You don't have that clickingand the popping and the pain
that you had preoperatively.

Speaker 1 (28:08):
So it's essentially replacing the ball and socket
joint.
You, you're giving the patienta new ball and a new socket, and
the new ball made out of metal,the new socket, made out of
plastic, feels no pain, right,so you're it's.
The analogy I like to give inother joint replacements is like
capping a tooth type of thing.
We still keep the patient'sbone, but we put a new cap on it

(28:33):
.
The cap is now feeling no pain,it's a.
It's a nice, smooth, shinysurface And it's a stable
construct.
How long have shoulderreplacements been around?

Speaker 2 (28:45):
They've been around It's since the 1950s, but
they've evolved over time andoriginally it started out as a
salvage procedure, in particular, especially with the reverse
shoulder replacements, and theywere used primarily to treat
Complex fractures that existedas well as different tumor
conditions that exist in theshoulder, unfortunately, in the
beginning had a high failurerate, to be honest with you, and

(29:08):
we've gone through multiplegenerations of implant designs
now Where they're very stableand initially they had very long
stems and we're actually usinga lot of metal to replace just a
small piece of bone just tokeep that stable, especially in
the humeral component, and We'reusing a lot of cement in the
plastic component to hold thatin place and keep it from

(29:28):
getting unstable over time orloose and over time.
But obviously, as technologyhas advanced you you know We we
don't really put in a lot ofmetal now when we do shoulder
replacements.
It's actually very, veryminimal and most patients are
surprised when I show them inthe office on an x-ray Or
pictures of the implants howmuch metal there really is and
it's far less than a hipreplacement or a knee

(29:50):
replacement.
It truly is a resurfacingprocedure that we do and
Oftentimes I would say the vastmajority of the shoulder
replacements that I do.
They don't even involve anystems.
There are these small press fitcomponents that we put in.
They're really adhere to thebone and and and allow for the
bone to grow into the implant toprovide stability over time.

(30:10):
So we're not even removing muchbone to begin with and we're
putting in a minimal amount ofmetal in terms of the plastic
component, the.
The implant that I particularlyuse Doesn't even involve the
use of a lot of cement.
It still involves a press fitcomponent to rely on the
majority of the stability and avery, very small amount of
cement that I use To keep thatin place.

(30:32):
Again, just because of the waythat the technology has advanced
, these are very, very stableimplants and the survivorship
The ten year survivorship isapproaching 96% in a lot of
studies.
So these implants are lasting avery, very long time and of
course, part of it is, you know,treating the shoulder well
after you get it, just like anyother joint replacement.
You want to treat it well, butthey they are lasting a very

(30:55):
long time and I tell patientswhen I give them a shoulder
replacement The goal is for themto have it for the rest of
their life.

Speaker 1 (31:01):
So let's demonstrate what we're talking about to our
patients.
Let's Present the model of theshoulder replacement system that
you use and we'll talk aboutthe anatomical Parts of the
shoulder and what gets replaced.
So, dr Su, why don't youexplain to our viewing audience
exactly what we're looking athere?

Speaker 2 (31:20):
so this is the shoulder joint and Analogous to
the golf ball, sitting on a golftee.
This is the humeral head boneand that's the golf ball
component, and here's a socketthat I mentioned or alluded to
earlier, which is the golf tee.

Speaker 1 (31:33):
So let's talk about that.
So this is the golf ball andthis is the golf tee.
So this is an example of howsmall the golf tee would be, and
that's the analogy we oftengive for the shoulder joint.
So if you saw this tee in thisposition and the golf ball
sitting in this position, that'svery much analogous to a golf
ball on a golf tee and you cansee that's inherently a very

(31:55):
unstable Construct.
The cup of the ball and socketjoint is so small and the ball
is so big.
But the only reason thisshoulder becomes stable is
because of the dynamicStabilizers, the rotator cuff
muscles that we alluded tobefore, and also because of the
bony constraints from the, fromthis Articulation, as well as

(32:17):
the labrum and the capsule thatkeeps this bone socket joint
stable and together.
So that's the analogy of thebone socket joint of the
shoulder and this smooth whitesurface on the end of the bone.

Speaker 2 (32:30):
That's the articular cartilage that I mentioned
earlier.
So you know, here's the, therougher bone that is comprised
of the entire humerus And thisis the coating at the end of the
bone, which is the articularcartilage, and that's the smooth
part of the shoulder.
And if you look at the glenoidas well, which is right here,
there's a ring of tissue aroundthe glenoid which is a labral
tissue, and central to that isalso articular cartilage.

(32:52):
So it's the same smooth whitecoating that you see on the
humeral head And so you havesmooth articular cartilage on
the humeral head That'sarticulating with the smooth
cartilage on the glenoid yeah,so the labrum is like he
discussed, a Fibro cartilaginousstructure that
circumferentially wraps itselfaround the entire glenoid.

Speaker 1 (33:13):
It's essentially a Thickening in the capsule at its
insertion that, along with thecapsule, helps to stabilize the
Bone socket joint fromdislocating.
So that is a normal shoulderjoint, normal ball and socket
joint.
But in the face of arthritiswhat happens?

Speaker 2 (33:34):
So we get degradation or erosion of this smooth
cartilage that you see here, andso, as, as that starts to thin
out and erode, you get exposureof this rougher bone that you
see here Which comprises therest of the humerus, and so that
bone again is rough and as thatbecomes exposed, that is what
arthritis is.
And when we take an x-ray in theoffice You see that the joint

(33:55):
space is narrowing because thisarticular cartilage creates a
space between the two bones.
And when we take an x-ray inthe office we only see the bones
, we don't see the cartilage.
So when we look at an x-ray, wesee that there's a space
between those two bones and Theclassic bone-on-bone term for
arthritis that patients alwayshear about is that as that

(34:15):
Carilage starts to wear out, wedon't see that space anymore,
and so we see the two bonesstarting to go towards each
other and touch each other, andas this smooth white surface
starts to erode, we see that onthe x-ray the to the exposure of
the bone Becomes obvious andand that's what leads to the
thinning that you see on thex-ray right.

Speaker 1 (34:33):
So what are we looking at here, dr Sud?

Speaker 2 (34:36):
So this is an example of how a shoulder replacement
would look like and, as Imentioned earlier, we're not
removing a lot of bone and we'renot putting in a lot of metal
or plastic for that matter.
So the part of the cartilagethat was thinned out and exposed
We removed.
So we removed the part of thebone, and only the part of the
bone That's that's degraded andcausing pain.

(34:57):
We don't need to remove anymore than that.
And what we do is, once weremove that bone, we replace
that with a nice smooth metalimplant and, as you can see,
it's a hemisphere, it's not afull sphere.
And again, we're only replacingthat part that had the
articular cartilage on it.
We're not removing any morebone or replacing any more bone.

(35:17):
It's literally just the partthat had the exposed bone
underneath from the Articularcartilage erosion.
So this is how it would looklike on the humeral side, on the
glenoid side.
We put in a plastic componentand Basically what we do is we
remove whatever remainingcartilage is there that really
isn't doing much for the patientat that point and we replace it

(35:39):
with a smooth plastic componentand it's placed Press fit with
only a small amount of cementand we put that into the bone
and it's a very stable implantand That causes it, the glenoid
component, to have a smoothplastic component to it.
So once we've completed theshoulder replacement, we have
this smooth metal part on thehumerus, articulating with the

(36:02):
smooth plastic part on theglenoid bone, and You don't have
that bone-on-bone contactanymore.
Great, amazing.

Speaker 1 (36:11):
How do you do a shoulder replacement?
I mean, typically is this donein the hospitals, it done as an
outpatient.

Speaker 2 (36:18):
Oftentimes it can be done as an outpatient, and
that's where medicine is goingis outpatient genre placement.
Oftentimes patients wake upwith no pain.
Prior to undergoing a shoulderreplacement, vast majority of
patients get a pre-operativeblock by the anesthesia team, so
they get an injection and Theybasically numbs up the arm and

(36:39):
the body doesn't feel the thearm anymore And and that means
that the body doesn't experiencepain.
What that allows is, during theprocedure, the patient doesn't
require much anesthesia to keepthem asleep.
The body's not experiencing thepain, their their pulse isn't
elevating, they're verycomfortable and when patients
wake up, they wake up in no pain.

(36:59):
So it allows them to go homeand not have to stay in the
hospital, necessarily overnight,unless there's a medical reason
to keep them in the hospital.
Obviously we would do that, butthat's why the vast majority of
shoulder replacements are ableto go home is because they're
comfortable, they wake up, theyhave no pain and they're able to
recover at home, which is theideal situation for many
patients.

(37:20):
It's done in a minimallyinvasive fashion.
It's it when I talk to patientsabout a shoulder placement,
initially a lot of them haven'theard about it, so they don't
know how it's done or or or whatwe do and it sounds Like it's a
very, very big procedure, it'sactually done through one
incision.
So we make one incision in thefront part of the shoulder

(37:40):
several inches long, but it'sone incision.
It's not on the side, it's notin the back, just one incision
in the front.
And When we do the exposurewe're dividing the muscles and
just opening up the plane to theshoulder and and we're able to
expose it Within 10, 15 minutes.
It really doesn't take muchtime.
To gain the exposure to theshoulder We do identify the

(38:01):
subscapularis rotator cufftendon and that part I take down
.
And Once I take thesubscapularis rotator cuff
tendon down and we have tovisualize the entire shoulder
joint from the front, once Ihave full exposure I remove
again only the part of the bonethat's arthritic.
It doesn't have cartilage on itanymore.
Usually I'll start out byexposing the humerus or the

(38:22):
humeral head on the arm part ofthe bone or the upper part of
that bone.
So we expose the humeral headpart of the bone and we just
remove the part of the bone thatdoesn't have a cartilage on it
anymore.
And as I mentioned earlier, youknow I've transitioned to not
using these big stem implantswith a lot of metal.
I always evaluate the boneintraoperatively and as long as
the bone quality is good and thevast majority of the patients

(38:44):
have sufficient good bonequality to be able to use a
stemless implant, and so thatgets put into place and Exposure
of the glenoid or the socketpart of the shoulder is is is
can be challenging at times fora lot of surgeons And that's why
, in the hands of someone who'sexperienced it can, it can go
very quickly, which is alwaysthe ideal situation, with less
anesthesia time.
You know, i'm able to preparethe glenoid and put the plastic

(39:07):
part of it within severalminutes With precision.
Now, with the technology that weutilize intraoperatively.
That technology involves theuse of getting a preoperative CT
scan that we do prior tosurgery and With that CT scan I
Import those images into acomputer software program which
regenerates the shoulder in a 3danatomic model and Based on

(39:31):
that anatomic model I'm able todesign a custom guide that I use
to to prepare the glenoidsurface while I'm in surgery.
Precise placement of the guide,pin off that guide is
Everything with the surgery,because even if you're off by a
few degrees, it can change theoutcome of the patient.
So precision is very, veryimportant for the placement of

(39:51):
the guide pin and preparation ofthe glenoid component.
That guy that gets made getsplaced right onto the glenoid
and it's custom.
So if it's perfectly like aglove onto the glenoid, once
it's perfectly onto the glenoidI advanced the guide pin into
the glenoid and, based off thatone single pin, i'm able to do
the entire part of the procedurethat involves the glenoid.

Speaker 1 (40:12):
I'm so excited to know that, in the area of
shoulder replacement surgery,you're utilizing the
technologies that we've beenusing for years now in the area
of hip and knee replacement.
Customized, patient specificjoint replacement surgery is
something I'm very, verypassionate about, and using
high-resolution cross-sectionalimaging modalities like MRI and

(40:34):
CAT scan to make sure that we'regiving each and every patient
the perfectly sized position andaligned implant is So important
in ensuring excellence in jointreplacement surgery and
outcomes as well for ourpatients.
So let's demonstrate what youdo in the area of shoulder
replacement surgery to ourpatients, how you customize each

(40:57):
and every joint replacement.
Okay, so what am I looking athere, dr Sue?

Speaker 2 (41:02):
So, based on that CT scan that I mentioned earlier,
where we recreate a 3d model ona computer, i designed the the
implant that I used duringsurgery to to allow for the
correct placement of the guidepin, and What we do is
preoperatively, once I plan iton the computer software,
there's a 3d printed model thatgets recreated to To shape the

(41:25):
actual glenoid that the patienthas, as well as the implant that
I want to use during surgery.
So here, on your right hand,you see an example of a 3d
printed model of a patient'sglenoid bone or the socket part
of the shoulder joint, and Yousee the little divots.
There's three divots on thefront and one in the back, and
The guide that I designed usingthe computer program has four

(41:48):
Hands, you could imagine, orprongs that that fit onto the
glenoid like a glove.

Speaker 1 (41:53):
There's three prongs in the front, one in the back,
and I am able to Position itexactly where I want during
surgery And and that's how theguide is printed- So, for
instance, on this Model of thispatient's Glenoid, this is the
guide that you will create tosnap on to that patient's

(42:15):
glenoid Intraoperatively, justlike that Yes, correct, and
that's got the guide holes in itso that you know where to drill
your pins in preparation foryour glenoid reaming.
So, for instance, this this isa model now of the patient's
Native glenoid that'sdegenerative and worn and this
guide will literally snap on,just like this, intraoperatively

(42:38):
.
You could see how it literallyfinds its happy place and it's
perfectly positioned right therefor you intraoperatively.
And through that guide, youhave these drill holes that
you'll shoot some pins, k wires,to allow you to continue the
reaming process.

Speaker 2 (42:58):
Yes, this guide allows me to place one central
guide wire in the center of theglenoid in the correct position
and again, even a few degreescan make a big difference in the
outcome for patients.
So this allows for the preciseplacement of that guide pin and
off that guide pin to be able toprepare the entire glenoid and
implant the final component.

Speaker 1 (43:16):
Wow, that's so exciting to know you have this
advanced technology and shoulderreplacement surgery as well.
Our patients are truly gettingthe best of the best in your
hands, for sure.
So what are we dealing withhere?
What am I holding here, dr Sud?
So this?

Speaker 2 (43:32):
is a model of the proximal humeral bone and here
you see that the humeral headhas been resurfaced with the
implant and there are twodifferent ways to fixate this
part of the component.
The more traditional way, orthe way that I used to do it,
was using a longer stem and ithad a porous coat here which
allows for the in growth of thebone and stability over time,

(43:55):
and we used to put that down thecanal of the humeral bone,
which provided a good fixationand tight fixation for stability
.
But as technology has advanced,we don't need to use as much
metal anymore and so I'veconverted primarily to using a
stemless implant, as long as thebone allows for it and we don't
need to use the stem.

(44:16):
So here's an example of that,for instance.
So this is an example of the ofthe stemless implant.

Speaker 1 (44:21):
Comparing contrasting to this.

Speaker 2 (44:25):
And so we prepare the , the proximal humeral bone.
We don't need to prepare thecanal like we used to for the
other implant, and because thetechnology that we have, and the
good on-growth or in-growthporous technology is able to
provide very secure fixation andthe failure rates on the
humeral component are low, andeven once we've transitioned to
the stemless implant, i've yetto have a single failure with

(44:48):
this type of device.

Speaker 1 (44:49):
I love it.
I love it just like otherfields of orthopedic medicine.
It's all about preserving boneright, preserving bone being
minimally invasive.
In the area of jointreplacement surgery in
particular, we always have tothink about the potential next
to operation and in the area ofshoulder, the humerus is a small
bone relative to, for instance,the knee and and we've done a

(45:14):
podcast about ankle replacementsas well, and Dr Rappaport
alluded to the fact that it'svery, very important to make
sure that he preserves everylittle bit of bone around that
ankle.
The shoulders got to be quitesimilar in that we're dealing
with very little bone stock,especially around the glenoid
and even the proximal humerus aswell, and it's really critical

(45:35):
for you to try to preserve bone,especially when, potentially,
the patient may require sometype of revision surgery down
the road.
So these less invasive implantsare becoming more and more
popular, i'm sure.

Speaker 2 (45:48):
Yes, they are, and the whole idea is to preserve
the normal anatomy and thenormal bone as much as possible.
And you're absolutely right, wealways want to think about the
next step.
It's easy to do it initially,but if, for some reason, we need
to go back in, we need the bonestock to work with and if we
were in a situation where weremove too much bone, there's
nothing to work with when we goback and and you're right, the

(46:10):
shoulders very similar to theankle, where there isn't that
much bone, it's not like a bighip joint or a big knee joint
and so there really isn't muchbone and we want to preserve as
much as we can initially.
And it's important becausethere's a lot of important soft
tissue structures that attach tothat bone too.
For example, on the on theproximal humerus side, where we
put the, the ball part of thecomponent, the, the rotator cuff

(46:32):
tendon, is attached all aroundthat bone to the tuberosities on
that proximal humerus.
So the greater tuberosity hasthe super spinaeus, the
infraspinatus, and on the backpart is a teres minor, and on
the lesser tuberosity on thefront part of that bone, the
subscapularis has its attachmentso we want to maintain those
attachments so that the shouldercan function as normal as

(46:53):
possible after the operation.

Speaker 1 (46:54):
100% so typically.
Dr Sudd, how long does theshoulder replacement take you in
the operating room to perform?

Speaker 2 (47:00):
The standard total shoulder replacement will take
me about 45 minutes to complete.

Speaker 1 (47:05):
So is everyone that presents to your office with
shoulder arthritis a candidatefor an anatomic total shoulder
replacement.

Speaker 2 (47:13):
There's a.
There's several things that welook at.
One of the most importantthings that we look at is the
integrity of the rotator cufftendons, because the the a good
outcome for a shoulderreplacement surgery depends on
not just the bone but also thesoft tissue structures that
surround that bone, and so itstill relies on intact rotator
cuff function for it to function.

(47:33):
So we always check, based onphysical exam as well as MRI in
some situations, to check forthe integrity of the rotator
cuff tendons, to see you know,once we replace the bone with
these implants, can it stillfunction, and so that's always
an important thing to look atpreoperatively.

Speaker 1 (47:49):
If somebody has a small rotator cuff tear, will
you still be able to do thistype of shoulder replacement?

Speaker 2 (47:56):
I will and and it's not not common but in a lot of
situations I'll repair therotator cuff tendon at the time
of the shoulder replacementsurgery.
And again, this is for very,very small tears where I don't
want to commit to a reverseshoulder replacement, which is
something we'll get into inanother podcast, which is a
different type of shoulderreplacement.
But if the patient has goodintegrity of the remaining

(48:18):
rotator cuff tendons and it'sjust a small tear and overall
they have good strength on exam,i will repair small rotator
cuff tears at the time of ashoulder replacement to try and
preserve the anatomy to be asnormal as possible.
And that's what we want.
We want to preserve the anatomyand just replace the bone that
we removed without making anysignificant anatomical changes

(48:39):
for the patient.

Speaker 1 (48:40):
So you mentioned that it takes you about 45 minutes
to do this operation.
Typically, when they're done,most patients will be discharged
the same day.
Some patients, for medicalreasons, may get admitted
overnight, but for the most partthey're discharged the same day
.
And what's life like after that?
what is a typicalrehabilitation course for these

(49:01):
patients?

Speaker 2 (49:03):
Surprisingly, the post-op or the pain after
shoulder replacement is not assignificant as patients might
think.
In fact the consensus would beit's far less than even an
arthroscopic rotator cuff repairwhere we're not removing any
bone or putting in any major,you know metal implants.
And again patients get theblock preoperatively so they're
able to go home very comfortablyand make the appropriate

(49:24):
transition to any pain andmedication that they might need.
And I would say in terms of allmy patients, the ones that get
shoulder replacements and theones where I do arthroscopic
rotator cuff repairs, laborrepairs etc.
I find that my shoulderreplacement patients need far
less pain medication and are farmore comfortable after surgery.
Usually they're placed into asling and I keep that sling in

(49:48):
place for about four weeks aftersurgery and that allows the
rotator cuff tendon to heal.
And again, as I mentionedearlier, i take down the sub
scapularis rotator cuff tendonto gain exposure to the shoulder
.
So we want it to heal and theprotection is mainly for that
rotator cuff tendon because theimplants that we put in are very
stable.
You could almost begin movingit right away.
After about four weeks we beginphysical therapy.

(50:10):
I teach a very intensive homeprogram that I want patients to
do on their own as well asphysical therapy and I tell
everyone that you know they usephysical therapy as a guide but
I really want them to do a lotof the exercises at home every
day, multiple times a day, toprevent stiffness and regain
that range of motion and get thestrength back.
Well, i could go to the gymwith a personal trainer two or

(50:30):
three times a week, likepatients do with physical
therapy, and if I come home andI don't exercise I'm eating
potato chips, not really dieting.
Well, they're exercising.
I won't really see the gainswith that personal trainer.
But if I use that personaltrainer, i come home and I
exercise on the side, i have agood diet, i'm trying to eat
right.
All of a sudden I'll see thosegains at an exponential rate.

(50:52):
And so I tell patients when theygo to physical therapy yes, i
want them to go, because it'svery, very important in the
beginning to have that help tomove the shoulder, because it
can be uncomfortable sometimesAnd patients just need that help
.
But I want them to come homeand do the exercises on the side
as well And that's when theyget that exponential recovery,
fast recovery with range ofmotion and strength, and so I

(51:13):
teach a very intensive homeprogram And they're basic
exercises that they do, but Iwant them to do them frequently
And as consistently as possible,and all my patients have.
You know, i don't have anyissues with compliance because
these are basic exercises.
At home does not require anyequipment, they just need the
commitment to it And when theydo these exercises, overall the
recovery is pretty quick And thegoal is to achieve full range

(51:35):
of motion.
You know, usually around six toeight weeks is where I want
them to have the full range ofmotion.

Speaker 1 (51:40):
So how long do you tell your patients it takes to
fully heal from this operation?

Speaker 2 (51:46):
I tell everyone I can take, I give an approximation
of about three to four months ofrecovery.
I mean I tell everyone, justlike any standard joint
replacement, that they're goingto expect improvements for even
upwards of a year.
But the biggest gain is goingto be that first three to four
months And at that point they'llfeel very comfortable doing
most of the activities that theywere doing prior to the
development of arthritis.

Speaker 1 (52:07):
And with respect to outcomes and patient
expectations, what do youtypically tell them?
their expectation should bewith respect to restoration of
function, range of motion,return to sports activities of
daily living, et cetera.

Speaker 2 (52:27):
In terms of range of motion, my expectation is that
it's as close to what's normalfor them as possible And where
the contralateral shoulder orthe other shoulder might be, or
where it was prior to the onsetof the arthritis.
So the goal is to achieve asfull range of motion as possible
In terms of activities.
That's the beauty of jointreplacement surgeries.

(52:48):
We want patients to get back todoing as much as possible.
We don't want to limit too much.
We want them to live their lifeand enjoy and do the things
that they want to do pain-free.
There's just a couple of thingsI recommend they avoid, which
is excessive force or axialforce through the shoulder.
So if they're able toaccommodate, maybe avoid doing
heavy push-ups or heavy benchpress exercises or military

(53:11):
presses.
It doesn't mean that they can'twork out at all, they still can
.
It's just that maybe take someof the load off the shoulder.
But in terms of doing sportsactivities or recreational
activities, they could prettymuch do everything that they
want to do.
And do I have some patients thatgo back to doing push-ups and
bench press and do great,absolutely.
But in general we want to avoidtoo much excessive force And my

(53:33):
analogy again to that is havinga nice car.
And if you have a very, verynice car, a fast sports car, you
look at one of the days thatyou drive it.
Right, you're going to drive iton a nice sunny day on a smooth
road, but it's a car.
Technically it can go anywhere.
You can go off-roading with iton a gravel road if you want to,
but you don't.
You want to treat it well, andso my analogy to patients is I'm

(53:56):
giving them a nice car, whichis their shoulder, and I just
want them to treat it well.
It doesn't mean you can't docertain things, just that If you
have a nice shoulderreplacement, take it out on a
nice sunny day on a smooth roadand treat it well, and the goal
is for it to last forever.

Speaker 1 (54:10):
Yeah, i mean it's just like any other joint
replacement.
We want patients to be able torestore their quality of life
And that's why, in fact, we'redoing the operations.
But don't abuse it.
Every once in a while, if theyhave a knee replacement, they
want to run on it.
Run, but don't run marathonswith your knee replacement.
But if you have to run to playa pickup game with your kids

(54:32):
basketball or whatever by allmeans run, enjoy it.
But try not to choose toparticipate in sports or
exercise activities that willpotentially lead to premature
wear of the construct And, withrespect to the shoulder and also
other joints, high impactaerobic activity tends to

(54:54):
potentially increase the risk ofwear and tear.
But by all means, we're doingthese operations so that our
patients can restore theirquality of life, live life to
its fullest and, just for themost part, use common sense in
that regard.
In general, especially in thearea of hip and knee replacement
surgery, we favor fluid-likeexercise regimen, and the

(55:17):
shoulder is quite similar.
Just try to avoid that highimpact, the push-ups, et cetera,
but certainly golf, tennis,things like that, swimming I'm
sure you encourage all thoseexercises, right, Absolutely,
and for the most part, mostpatients are extremely satisfied
.
Being told that, and just to getout of pain, especially at
night, and to be able to have agood night's sleep because your

(55:40):
shoulder is not bothering you,is so rewarding I'm sure that
shoulder replacement surgery inyour area of expertise is
probably, i would say, the mostrewarding procedure you do.
Is that true?

Speaker 2 (55:52):
It absolutely is, and almost immediately
postoperatively, especially thepatients that had that night
pain that we were talking aboutearlier.
Vast majority of the time thepatients come to their first
postop visit and they say thatwithin one or two days that
night pain that they hadcompletely goes away.
It's a different kind of painbecause they're recovering from
an operation But that deep, dull, toothache-type pain that they

(56:15):
were experiencing before iscompletely gone And to them the
recovery or any minimal painthat they have from the
operation itself, that's atrade-off they're willing to
take all day, every day, becauseit's minimal compared to what
they were experiencingpreoperatively.

Speaker 1 (56:29):
Well, as I alluded to earlier in the podcast, dr Sud,
i will forever be indebted toyour wife for being a Jersey
girl and to bringing you backhome from France.
We're just so blessed to haveyou at the Kaila Orthopedic
Center.
You know how I feel about youand your skill set, especially
as well in the area of shouldersurgery.
You are a master shouldersurgeon.

(56:51):
You've cared for thousands andthousands of our patients over
the years and helped themrestore that quality of life
that they were yearning for, andso we're very appreciative of
your excellence and yourexpertise, and I just want to
sincerely thank you for joiningme on this podcast today, and I
truly look forward to having youback again to discuss many
other shoulder ailments, such asrotator cuff tears, labral

(57:14):
tears, biceps tendon conditions,ac, joint separations and the
reverse total shoulderarthroplasty that Dr Sud
referred to earlier.
So thank you so much.
We hope that this podcast wasvery informative to you and your
family and friends, and if youfound this helpful and
entertaining and informative, wewould appreciate you

(57:36):
subscribing to our Kaila Orthochannel.
Thank you, have a great day.

Speaker 2 (57:41):
Thank you, thanks so much, thank you.