August 13, 2025 • 28 mins
The shoulder is the most mobile and most complex joint in the human body, which also makes it vulnerable to injury and arthritis. Each year, nearly 60,000 Americans undergo shoulder replacement surgery, also known as total shoulder arthroplasty (TSA).
In this episode of MedStar Health DocTalk, host Debra Schindler sits down with orthopedic surgeon Dr. Ryan Hoffman, a shoulder and elbow specialist at MedStar Health, to explore:
· What shoulder arthroplasty is and when it’s needed
· The difference between total vs. reverse shoulder replacements
· How advances like robotic planning, 3D templating, and stemless implants are changing outcomes
· What recovery looks like and how patients regain mobility
· What to ask when choosing a shoulder surgeon
If you’ve ever wondered about shoulder pain, rotator cuff tears, or when it’s time to consider replacement surgery, this conversation breaks it all down.
Watch and learn how modern shoulder surgery is helping patients get back to the life they love.
For an appointment with Dr. Hoffman call 410-554-2272. If you would like to share feedback on this podcast or suggest a topic for another episode of MedStar Health Doc talk, send an email: debra.schindler@medstar.net.
For more episodes of MedStar Health DocTalk, go to medstarhealth.org/doctalk.
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Episode Transcript
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(00:01):
Comprehensive,relevant and insightful conversations
about health and medicine happen here.
When MedStar Health Doc talk,these are real conversations with
physician experts from around the largesthealthcare system in
the Maryland DC region.
It's well established and medicalcommunities that the large ball and socket
(00:21):
joint of the shoulder has a wider rangeof motion than any joint in the human
body. It's a complicated joint. It'snot as stable as a hip or a knee,
which makes it prone to injury requiringthat ball and socket be replaced.
This year,nearly 60,000 Americans will need a
shoulder replacement surgery known asshoulder arthroplasty.
(00:42):
The good news is that placing theshoulder joint has advanced by strides in
recent years with improvedimplants, robotic planning,
minimally invasive techniques,and even outpatient procedures that
have you going home the same day.
We're going to get all the details onthem and more with orthopedic surgeon,
Dr. Ryan Hoffman, a shoulder andelbow specialist at MedStar Health.
(01:04):
I'm your host, Deborah Schindler.
Thanks for being with ustoday on doc talk Dr. Hoffman.
Thanks for having me.
I'm happy to be here.
So sometimes I hear this surgery referredto as a total shoulder replacement or
a total shoulder arthroplastyand then TSA for short,
it's all the same thing, right?
Can you explain exactly whatshoulder arthroplasty is?
(01:26):
Sure. That's a great question.
So shoulder arthroplasty is replacingthe opponents of your joint,
so it is a ball and socket joint.
It is putting implants infor the ball and the socket.
Now the interesting thing is that we canactually do these conventionally where
we replace the ball with another balland the socket with something that looks
(01:48):
like a little piece of plastic and itgoes right in the socket and it looks just
like your normal shoulder justwith implants in. Alternatively,
we can reverse that.
So the other version of a shoulderarthroplasty is a reverse shoulder
arthroplasty where instead of theball being on the humerus side,
the ball is actually on the socket sideand the socket is on the humerus side.
(02:11):
And typically that was initially adaptedfor patients that had rotator cuff
tears and injuries that we couldn'tfix and they had trouble with motion.
However, the uses of that have beenexpanding significantly over the years.
Correct.
I think most of us are familiar withthe bow and socket joint in the shoulder
that I mentioned earlier, but there isa much more complex network of bones,
(02:32):
muscles, tendons.
Can you give us a little bit of backgroundor understanding of the anatomy of
the shoulder and what happens thatrequires the joint to be replaced?
Sure.
The two largest conditions that end upresulting in shoulder replacements are
one glenohumeral osteoarthritisor just standard shoulder
arthritis. In that condition, what wehave is we have a layer of cartilage,
(02:56):
which is just a really smooth layerthat lines the joints and allows them to
move freely without pain.
Now in some individuals over yearsand over time the cartilage kind of
begins to deteriorate and then eventuallyit becomes bone grinding on bone
and that can be quite painful.
It can be debilitating.
We can have significant decreasesin range of motion and for those,
(03:19):
that's where the traditional standardanatomic total shoulder arthroplasty came
into play because we can'treally replace cartilage,
but we can replace the joints with kindof plastic and metal depending on where
you are and that can give us a freelygliding joint that allows us to have more
motion.
The second type is considered with rotatorcuff tear arthropathy or if patients
(03:40):
have really big rotatorcuff tears in the past,
a standard shoulder replacement wouldnot work because the rotator cuff is what
allows us to function. It's whatallows us to really move our shoulders.
However, by reversing the implants,it allows your deltoid muscle,
which is not your rotator cuff,to take over and restore function to
patients where it might not have been thecase decades ago.
(04:05):
What exactly is the rotator cuff? Ireally don't even understand what it is.
It's a great question. Iget that literally every
it's essentially a sleeve of musclesthat turn into tendons and they attach to
the top of the shoulder bone and whatthey do is they allow you to move your
shoulder freely in different directions.
(04:25):
Now the problem comes whenyou have rotator cuff tears
in how we can actuallyraise and move our arms.
So a lot of times there are tons ofpeople that live their lives with big
rotator cuff tears or if they fall andthey sustain one and they can't lift
their arm up and they end uphaving these terrible injuries that
(04:46):
hopefully we get to them inside. There'salways things that we can do for them.
But the rotator cuff is a veryimportant structure that we have to take
seriously because it allows us to reallymove our arms how we'd like to do.
Apart from a fall or a sudden injury,what's usually the first indication
a person has that they need to see ashoulder surgeon?
So I would say pain and weakness are thetwo most common things I happen to see.
(05:12):
Typically, pain is the biggestdriving force without an injury.
Now oftentimes patients will see theirprimary care physicians and they'll try
physical therapy.
Sometimes they will try injections andreally when we have pain that doesn't
respond to physical therapy or injections,then that is a time where I think
it's very important to see a shoulderspecialist because a lot of the times we
(05:35):
live our lives with pain that we don'tnecessarily have to.
There are a lot of people that don't knowthat shoulder replacements or specific
shoulder surgeries exist and they end upjust living their lives with what they
call their bad shoulder.
And the things we pride ourselves in istaking away the term of bad shoulder.
(05:55):
We can always do something for,we can almost always fix it.
We can always do things to make it improveand we can try to restore quality of
life to individuals who didn't knowthat that was an option in the past.
Well,shoulder pain can mean a lot of things
though it doesn't necessarily mean thatthe person needs a shoulder replacement.
So what's your advice to listeners whoare trying to figure out what the source
(06:19):
of their pain is? How is that diagnosed?
So that's a great question. Typically,if it's not associated
with a fall or an injury,a lot of times simple shoulder pain
from overuse injuries will go away withtime. If you rest, you take it easy ice.
These are things that often can bevery helpful with physical therapy too.
(06:42):
Rotator cuff tendonitis oranything that you have in there,
a lot of the times can be treated.
It's that pain that really just doesn'tgo away with time kind of gets worse
over time when it startsturning into weakness.
These are other things we can look for.
If you have persistentgrinding in the shoulder,
that's another thing that issomething that we can look into,
(07:03):
but it's really pain that doesn'tget better. With physical therapy,
I have a lot of patients that willcome in and they have mixed opinions on
physical therapy and I'll tell you as aformer shoulder surgery patient myself,
I think physical therapy is phenomenal.
I think it works great for theshoulder and when it stops working,
I think those are times when we need toreally start looking at what the bigger
(07:25):
picture is and why we'restill having these issues.
What do you mean by that?
They don't agree with getting physicaltherapy as a means of trying to eliminate
the pain or they just don'twant to do it because it hurts?
Just say that there's some individualswho they have preconceived notions about
physical therapy.
Sometimes people will tell individualsto go to physical therapy and patients
(07:46):
will sometimes view that as a, I don'thave anything else more for you to do,
but in actuality, physical therapyis a really phenomenal thing.
The shoulder is such a unique joint,there's so many different
areas that we need to balance.
There's force couples in theshoulder and by strengthening one,
you decrease the force on another.
And physical therapy itselfis a phenomenal thing that
(08:08):
shoulder.
The other thing is I think some patientsdon't always want to go to physical
therapy. It's time consuming.
It is hard to get off of work.
Sometimes the hours are tricky,but in all the patients that I've had
go and they've been very happy with itbecause they have been able to see the
gains that they can make and the stridesthe physical therapy can actually provide
in a lot of these general shoulderconditions.
(08:32):
At what point would you order up imagingand what kind of imaging would be
necessary for you to say to apatient that they need arthroplasty?
So I always start with x-rays. Ithink when you have shoulder pain,
it's always important tohave x-rays because you never
find and there are a lot of differentvariants that you can see that can lead to
different types of shoulderissues. What I typically do,
(08:55):
I base a lot of these off x-raysand if we're looking at shoulder
arthritis in general,an MRI is really helpful and it shows
us if the rotator cuff is of goodquality. As we mentioned, the rotator
cuff's important to move the shoulder.
If we're going to do astandard shoulder replacement,
you need to have a really goodrotator cuff. So in general,
(09:18):
I look at advanced imaging when we haveno longer responded to conservative
management like physical therapy orinjections and we're looking to see if we
want to go down a surgical route.
So really I use MRIs for patientswith standard arthritis just so I
can see the quality of the rotator cuffand make sure there's no surprises.
(09:38):
What are you exactly looking for?
So that's great. So I look for tears.
I look to see if the qualityof the rotator cuff tendon
especially over certain ages,can have underlying tears that they
never knew about just from the wear andterror of life.
So those are things that I look for tomake sure that we don't have an increased
risk of the implant failingat a sooner period of time.
(09:59):
Other things I look for is I look forlittle fluid collections that you can see
in the bone called cysts and look tosee how good of a quality the bone is
because these are also things thatwe want to look for whenever we do a
surgery.
We want to maximize the chances of thisbeing the last surgery anyone's going to
ever have. And I think themore information we have,
(10:20):
the better so that we improve the ratesof having the most successful outcome
possible. Do.
You ever get in and youlook at the imaging and find
shoulder at all, thatthey have shoulder pain,
but it is not even the shoulderthat is causing the pain?
I see that every day. It's.
Usually the culprit. What is.
So that is an excellent question.
(10:41):
Oftentimes what can happen is patientscan have pinched nerves in their neck and
when you have a pinchednerve in your neck,
a lot of times it gives you pain thatcomes down your arm into your shoulder and
it makes it feel likeyou're having shoulder pain,
but it's actually coming from your neck.
Ways that we can kind of help identifythat is a lot of shooting pain that kind
(11:01):
of goes up into your neck, numbnessand tingling that shoots down your arm,
pain that comes down past the elbow.
These are all indicators a lot of thetime that patients have a pinched nerve in
their neck.
And that would probably reallybenefit from physical therapy.
Absolutely. So physical therapy,we have a lot of great spine doctors
here at MedStar and I have a lot ofcolleagues that I'll refer some of these
(11:25):
patients to so that we can maximizetheir outcome.
Okay. So you see that the rotatorcuff is in fair condition,
but there's minimal cartilage and thatthe patient has a lot of pain and you
know that they need anarthroplasty. How long do they wait?
What's the right time for that surgery?
(11:46):
There's a lot of things thatwe kind of factor in there.
One is how bad the arthritis is.
I have a lot of patients that come inand their arthritis is not that bad.
It just gives them a little bit of painhere and there and they're not ready for
a surgery. And in patients thataren't ready for a surgery,
I don't force it on them.
My job is to give the risks and benefitsof all options and to help the patient
(12:08):
make the best decision thatthey feel is they can make.
So one of the other things wekind of look for sometimes age.
I do have a lot of young patientswith pretty bad arthritis,
which is a little rare,but the thing is implants are not
meant to last a hundred years,so we have to factor in lifetime when
or basically number of years whenwe look and see what implants we're
(12:30):
going to use or when we're going to do anarthroplasty. But it is something
that we take into consideration.
That being said,I do have a lot of young patients that
have had great outcomes from shoulderreplacements.
Isn't that interesting because you wouldthink that by the time the joint wears
out, the patient would bemaybe in their seventies,
but I have read thatthey're getting younger.
(12:51):
Is that because maybe of sports orplaying year-round sports or I don't know.
Athletics?
That's a really good question.
There's a number of conditions.
I will tell you that with moreand more high contact sports,
their rates of dislocationsin shoulders has increased.
Sometimes when you haveshoulder instability where
(13:12):
out, it can increase your risk ofdeveloping arthritis and sometimes,
sometimes certain procedures that areintended to stabilize the shoulder can
result in patients getting arthritisat an earlier age than normal at a
sacrifice of having a more stableshoulder at a younger period of time.
In addition to that, some people justhave a higher predisposition for it.
(13:35):
Some people have very tough manual laborpositions that put you at a higher risk
and some people just havegenetic conditions that
risk of needing a shoulderreplacement. I mean,
there's just a lot ofthings that can drive it.
I mentioned that thetechnology has just advanced
strides in shoulder replacement.
(13:57):
I know it has in the past 20 yearsthat I've been here working at MedStar
Health. Let's talk about that.
Let's talk about the advancements andyou mentioned the reverse shoulder
replacement, which is an amazingkind of reconfiguration of what
nature created,taking the ball and make it into a socket
and taking the socket and making itinto a ball.
(14:18):
Who exactly would benefit from that kindof change in the anatomy and what is
the end result for that? Do the patientsstill have the same kind of motion?
So historically,the best patients for the
reverse replacement were tear.
They could not be repaired or those whohad such bad rotator cuff tears that
(14:38):
they started to have different changesto their joint that couldn't be treated
with a standard shoulderreplacement. That is still the case.
Patients that have rotator cuff tearsthat we can't fix a lot of times can
benefit very much from a reverseshoulder replacement. However,
there have been more and more studiesrecently that show that you can do a
reverse shoulder replacementfor conventional arthritis too,
(15:00):
and patients still have excellent rangeof motion and they have excellent pain
control. So it really kind of varies.
Now you can actually utilize a reverseshoulder replacement for a number of
things.
I am very selective in when I use ananatomic versus a reverse shoulder
replacement,but the indications for them have
been increasing significantly.
Why might you use that if theperson's rotator cuff was fine,
(15:24):
why might you opt for areverse shoulder replacement?
So one of the things that you look forwith a standard shoulder replacement is
you want to make sure that the socketcan sit well or the piece or the material
we use to recreate the socketcan sit well in the bone.
Now in some of the patients,they have different types of
wear or erosion of the socket,which makes it challenging to get
(15:46):
good coverage of the new socket.
And if you don't have good seeding of it,it can result in early failure or if you
have different degrees that the socketis tilted, that can also make it
challenging and result in early failure.
So in patients like that,we typically tend to go to a more
constrained device such as the reverseshoulder replacement is it's more
(16:08):
predictable, you have better coverage,lesser chance of there being failure from
essentially the piece of plastic thatis not seated very well in the bone.
So we really look at the glenoid side orthe socket side when we're making these
decisions and make sure that we can puteverything in the best way possible.
Is it different in terms of the lengthof the surgery or how big the incision is
(16:32):
or the recovery?
So the length of surgery isabout the same for both of them.
I would say the incision is theexact same incision for both of them.
Which is about how manyinches would you say?
It's about four to five inches.
Four to five inches front of thepatient's shoulder, front of the shoulder,
(16:52):
kind of coming from just kind of insideof the shoulder up top down to the mid
level of the arm bone.
Okay.
And then after the surgeryand the recovery processes
be different? And getting back to thatquestion, do they have the same motion?
So the recovery period is pretty similar.
We typically start patientswith range of motion early on,
(17:13):
but there is a period of time wherethey're in a sling. For my patients,
I have them in a slingfor about six weeks.
I start assistive range of motionearly on for about six weeks.
After six weeks we startdoing active range of motion,
removing the arm on its own at threemonths we start doing strengthening at six
months. There's kind of fewerrestrictions in terms of range of motion
(17:37):
in general, both surgeries, the range ofmotion is great. Patients do very well.
It has been my experience.
I think that patients with anatomicshoulder replacements get a little bit
better internal rotation,so reaching up their back.
But in terms of forwardelevation and external rotation,
if the rotator cuff is intact,there are great studies that show that
both types of replacements can result insimilar outcomes.
(18:03):
It kind of just varies on how muchof the rotator cuff is intact.
Okay. Let's get to the next advancement.
And that's stemless shoulder replacement.
Can you explain what that is?
Sure. So shoulder replacements,they conventionally have had
a stem, which is just a long,it's a long part of the metal that
goes down the center of the tube,which is the canal of the humerus.
(18:28):
And in the past allimplants have had that,
but more recently we'vedeveloped stemless,
which is a smaller componentthat actually is bone preserving.
So it actually results, ifyou ever need another surgery,
it makes it for a much easier procedure.
There's less bone that needs to beremoved and it's really quite fascinating.
(18:49):
It was mostly used in anatomictotal shoulder replacements,
but we're currently in a few governmentstudies now looking at its use in
reverse.
How does that benefit the patientand why would they want that?
I think one of the ways that it benefitsthem is that it's bone preserving.
If you ever need anothersurgery in the future,
(19:10):
it makes for a significantlyeasier procedure or a less complex
procedure. One of the issues issometimes when we do these procedures,
it can result in significant boneloss if they need to be revised.
The other thing is that sometimes patientshave a lot of deformity from prior
fractures and that can make it reallychallenging to put a stem down,
(19:31):
a not straight bone.
But with a stemless procedureor stemless implant,
you can really tailor thatto the patient's anatomy
you can do with what you have.
How does it hold onto the boneif it's not hammered into that
implant and that stem gethammered into that bone?
So I'm wondering how theSTEM was would even hold on.
(19:54):
How secure is it in your body?
I'll tell you, it is very secure.
There's different types of metalmaterial that we use. They can be porous,
they can have little grip blasting,but essentially the bone can form on
and inside of it and it kind of formsaround it and kind of incorporates
it into it. And it is quite strong.
(20:14):
I tell you, they get such great fixation.
And there's nothing thatwould be different in putting
what the patient needs to know andmanaging their expectations about the
surgery, the length of thesurgery or the recovery.
Getting a STEMIs doesn'tchange anything for them?
No, it does not. I've actually foundthe surgeries are a little bit faster,
but it's not significant. Andin terms of their recovery,
(20:38):
it does not have any impact.
Oh, okay. Alright. Whatabout 3D templating?
I think 3D templating is fantastic.
It is that we utilize to helptailor the procedure so that it is
the most specific for each patient.
And what that is is when wedo shoulder replacements,
we have patients get CAT scans.
(20:59):
And what that does is it allows us tolook at the bones and what worth two
dimensional views and we can convertthem into a three-dimensional view on the
computer and we can then planthe surgery specific to the
patient's anatomy so we can reallytailor this as much as possible so that
each patient gets the mostspecific accurate surgery possible
(21:22):
directly related to their own anatomy.
So it's for planning?
Absolutely.
Planning.
You're not looking at a 3D templateduring this actual surgery or just using.
For planning? So what we use it forhere is that we use it for planning.
There are some companies that do havemixed reality glasses that you can use
them in the operating room and that'sa really interesting area that we have
(21:46):
been looking into moving forward,but that is one area of advancement,
but currently we'reusing them for planning.
I know we used 3D printing ona tus bone that was replaced.
Very cool technology.
It is pretty cool. And I'll tell you,so we actually do a lot of
custom shoulder replacements.
Patients where there's so much bone lossthat conventional implants don't work
(22:09):
and we actually work with certaincompanies that 3D create certain
implants that will fit into those defects.
And apart from just 3Dtemplating on the computer,
we can actually design implants thatwe've used in individuals and we can
also design different models so we cansee how our implants will fit in the
(22:29):
patient. And that's anotherunique thing that we do here.
That is very cool.
The implants that we've been talking aboutused in shoulder arthroplasty are all
different. What do patients need to knowabout them? What makes them different?
What makes them better? Should theyask their doctor for anything specific?
How would they know what to ask for?
I think ultimately whenyou're looking at a shoulder
(22:52):
replacement,the biggest thing is that you want to
have trust in the person who's doing itand you want them to use the implants
that they are going to do the best job foryou. However, there are very
interesting technologies that are out.
One of the things are we havehighly cross-linked polyethylene,
which is a specifically manufacturedtype of plastic that we use.
(23:13):
And then when it's alsocoated with vitamin E,
it is something that myself and theshoulder division here we are very
interested in using because we believethat it has lower rates of wear
and creating issues forpatients down the road.
That's one thing that we typically use.
The use of pyro carb or useof hydrocarbon in shoulder
arthroplasty is of another in interestingfeature that we utilize here as well.
(23:37):
It's a different type of material thanthe conventional metals that are used in
standard shoulder arthroplasty.
It's kind of a material on bone andour goal is that it decreases the
risk and the rate that you have whereand needing another shoulder surgery in
the future and that is something thatwe certainly utilize here at MedStar.
(23:59):
I think ultimately though,when you're looking at these,
I think it's always importantto ask what implants the
surgeon uses if they use anything new orinnovative
and if they have experiencewith 3D templating.
I think 3D templating is fantasticand I think everyone should use it.
(24:19):
What should patients consider whendeciding on a shoulder surgeon?
Maybe they don't have one already orthey haven't been referred to one and the
shoulder program.
I think one thing is that you certainly,and there have been
studies looking at this,but you certainly want to go to somebody
who does a lot of shoulder arthroplastyif you have individuals who
do maybe five or 10 a year.
(24:43):
I think that the experience is not quitethere as much and I think that there
are certain differences thatyou can see in outcomes.
So I think volume is certainly asignificant thing that you need to ask.
I think duration of time,number of cases are
all important features.
And then I think philosophy too.
I think it's always really importantto understand what everybody's
(25:06):
postoperative procedures are,how they take you through
the postoperative period,what the hospital stay is like.
There's a lot of really unique thingsthat we do here that I think really show
in our patient satisfaction,but I definitely think you need to be
pretty selective when you're deciding whoyou finally go to have
(25:26):
your shoulder replaced.
Well, to that point,Helio published the results of a study
that showed total shoulder arthroplastyperformed by a high volume surgeon
may decrease medical and surgicalcomplications compared with those
who performed lower volumes.
Should patients ask how many totalshoulder replacements a surgeon has done
(25:47):
during a consult, would you be offendedby that question? As a surgeon, I.
Would tell you I don't think I'moffended by any question I get asked.
You never know whatyou're going to get asked.
Good to know.
I'm an open book. I answerall questions that are asked.
So I personally am not offendedby anything that is asked,
especially when you're making such animportant decision as to having a part of
(26:08):
your body replaced.
It's very personal decision and I don'tthink that anybody should be offended
when somebody's doing their due diligenceand trying to do their homework and
make sure they make the bestdecision possible. I mean,
especially when there's so manypeople that dabble in different areas,
you want to make sure that you go tosomebody who's really comfortable,
who does a lot of them and who can giveyou the outcome that you're looking for.
(26:33):
What would be a lot of them, what wouldbe a good number to make you feel safe?
I would say you want somebody whodoes at least 50 to a hundred a year.
Okay. With all the changes we've alreadyseen in the advancement of shoulder
arthroplasty, what do youthink the future holds?
So I think that's a really great question.
I think one of the things that thefuture holds is robotics and shoulder
(26:56):
surgery.
We've already seen great success withthat in total hip and knee surgery,
and we have more and more areas where wecan use robotics and shoulder surgery,
especially with shoulderreplacements Here at MedStar,
we actually have the technology for theseand this is definitely an area that we
are working towards implementingin our regular practice.
(27:17):
How would that work? Actually,to tell you what angle to put the
implant in or to put a screw in,I am thinking in terms of how it
works for other orthopedic surgeries.
I think one of the ways that people haveutilized or one of the ways that people
have utilized it are making sure that wemake perfect cuts when we make our cuts
for the humerus or puttingthe implants into the socket.
Sometimes the deformity that you cansee in the socket can be a little tricky
(27:40):
and unless you do a lot of them,getting certain trajectories can be
a little bit challenging for some.
And what robotics allows us todo is to be extremely accurate to
make sure that we don't have any issuesto make sure that the implants are
placed and all of the cuts are madein the most perfect way possible.
They kind of take out a lot ofthe guess and check aspect of it.
(28:03):
We've been talking with MedStarHealth Shoulder and elbow surgeon,
Dr. Ryan Hoffman.
Thank you for sharing your expertise withus here on Doc talk for an appointment
with Dr. Hoffman off4 1 0 5 5 4 2 2 7 2.
If you would like to share feedbackon this podcast or suggest a topic for
another episode ofMedStar Health Doc talk,
(28:24):
send me an email Deborahschindler@medstar.net.
Comprehensive,relevant and insightful conversations
about health and medicine happen here.
When MedStar Health Doc talk,these are real conversations with
physician experts from around the largesthealthcare system in
the Maryland DC region.
It's well established and medicalcommunities that the large ball and socket
(00:21):
joint of the shoulder has a wider rangeof motion than any joint in the human
body. It's a complicated joint. It'snot as stable as a hip or a knee,
which makes it prone to injury requiringthat ball and socket be replaced.
This year,nearly 60,000 Americans will need a
shoulder replacement surgery known asshoulder arthroplasty.
(00:42):
The good news is that placing theshoulder joint has advanced by strides in
recent years with improvedimplants, robotic planning,
minimally invasive techniques,and even outpatient procedures that
have you going home the same day.
We're going to get all the details onthem and more with orthopedic surgeon,
Dr. Ryan Hoffman, a shoulder andelbow specialist at MedStar Health.
(01:04):
I'm your host, Deborah Schindler.
Thanks for being with ustoday on doc talk Dr. Hoffman.
Thanks for having me.
I'm happy to be here.
So sometimes I hear this surgery referredto as a total shoulder replacement or
a total shoulder arthroplastyand then TSA for short,
it's all the same thing, right?
Can you explain exactly whatshoulder arthroplasty is?
(01:26):
Sure. That's a great question.
So shoulder arthroplasty is replacingthe opponents of your joint,
so it is a ball and socket joint.
It is putting implants infor the ball and the socket.
Now the interesting thing is that we canactually do these conventionally where
we replace the ball with another balland the socket with something that looks
(01:48):
like a little piece of plastic and itgoes right in the socket and it looks just
like your normal shoulder justwith implants in. Alternatively,
we can reverse that.
So the other version of a shoulderarthroplasty is a reverse shoulder
arthroplasty where instead of theball being on the humerus side,
the ball is actually on the socket sideand the socket is on the humerus side.
(02:11):
And typically that was initially adaptedfor patients that had rotator cuff
tears and injuries that we couldn'tfix and they had trouble with motion.
However, the uses of that have beenexpanding significantly over the years.
Correct.
I think most of us are familiar withthe bow and socket joint in the shoulder
that I mentioned earlier, but there isa much more complex network of bones,
(02:32):
muscles, tendons.
Can you give us a little bit of backgroundor understanding of the anatomy of
the shoulder and what happens thatrequires the joint to be replaced?
Sure.
The two largest conditions that end upresulting in shoulder replacements are
one glenohumeral osteoarthritisor just standard shoulder
arthritis. In that condition, what wehave is we have a layer of cartilage,
(02:56):
which is just a really smooth layerthat lines the joints and allows them to
move freely without pain.
Now in some individuals over yearsand over time the cartilage kind of
begins to deteriorate and then eventuallyit becomes bone grinding on bone
and that can be quite painful.
It can be debilitating.
We can have significant decreasesin range of motion and for those,
(03:19):
that's where the traditional standardanatomic total shoulder arthroplasty came
into play because we can'treally replace cartilage,
but we can replace the joints with kindof plastic and metal depending on where
you are and that can give us a freelygliding joint that allows us to have more
motion.
The second type is considered with rotatorcuff tear arthropathy or if patients
(03:40):
have really big rotatorcuff tears in the past,
a standard shoulder replacement wouldnot work because the rotator cuff is what
allows us to function. It's whatallows us to really move our shoulders.
However, by reversing the implants,it allows your deltoid muscle,
which is not your rotator cuff,to take over and restore function to
patients where it might not have been thecase decades ago.
(04:05):
What exactly is the rotator cuff? Ireally don't even understand what it is.
It's a great question. Iget that literally every
it's essentially a sleeve of musclesthat turn into tendons and they attach to
the top of the shoulder bone and whatthey do is they allow you to move your
shoulder freely in different directions.
(04:25):
Now the problem comes whenyou have rotator cuff tears
in how we can actuallyraise and move our arms.
So a lot of times there are tons ofpeople that live their lives with big
rotator cuff tears or if they fall andthey sustain one and they can't lift
their arm up and they end uphaving these terrible injuries that
(04:46):
hopefully we get to them inside. There'salways things that we can do for them.
But the rotator cuff is a veryimportant structure that we have to take
seriously because it allows us to reallymove our arms how we'd like to do.
Apart from a fall or a sudden injury,what's usually the first indication
a person has that they need to see ashoulder surgeon?
So I would say pain and weakness are thetwo most common things I happen to see.
(05:12):
Typically, pain is the biggestdriving force without an injury.
Now oftentimes patients will see theirprimary care physicians and they'll try
physical therapy.
Sometimes they will try injections andreally when we have pain that doesn't
respond to physical therapy or injections,then that is a time where I think
it's very important to see a shoulderspecialist because a lot of the times we
(05:35):
live our lives with pain that we don'tnecessarily have to.
There are a lot of people that don't knowthat shoulder replacements or specific
shoulder surgeries exist and they end upjust living their lives with what they
call their bad shoulder.
And the things we pride ourselves in istaking away the term of bad shoulder.
(05:55):
We can always do something for,we can almost always fix it.
We can always do things to make it improveand we can try to restore quality of
life to individuals who didn't knowthat that was an option in the past.
Well,shoulder pain can mean a lot of things
though it doesn't necessarily mean thatthe person needs a shoulder replacement.
So what's your advice to listeners whoare trying to figure out what the source
(06:19):
of their pain is? How is that diagnosed?
So that's a great question. Typically,if it's not associated
with a fall or an injury,a lot of times simple shoulder pain
from overuse injuries will go away withtime. If you rest, you take it easy ice.
These are things that often can bevery helpful with physical therapy too.
(06:42):
Rotator cuff tendonitis oranything that you have in there,
a lot of the times can be treated.
It's that pain that really just doesn'tgo away with time kind of gets worse
over time when it startsturning into weakness.
These are other things we can look for.
If you have persistentgrinding in the shoulder,
that's another thing that issomething that we can look into,
(07:03):
but it's really pain that doesn'tget better. With physical therapy,
I have a lot of patients that willcome in and they have mixed opinions on
physical therapy and I'll tell you as aformer shoulder surgery patient myself,
I think physical therapy is phenomenal.
I think it works great for theshoulder and when it stops working,
I think those are times when we need toreally start looking at what the bigger
(07:25):
picture is and why we'restill having these issues.
What do you mean by that?
They don't agree with getting physicaltherapy as a means of trying to eliminate
the pain or they just don'twant to do it because it hurts?
Just say that there's some individualswho they have preconceived notions about
physical therapy.
Sometimes people will tell individualsto go to physical therapy and patients
(07:46):
will sometimes view that as a, I don'thave anything else more for you to do,
but in actuality, physical therapyis a really phenomenal thing.
The shoulder is such a unique joint,there's so many different
areas that we need to balance.
There's force couples in theshoulder and by strengthening one,
you decrease the force on another.
And physical therapy itselfis a phenomenal thing that
(08:08):
shoulder.
The other thing is I think some patientsdon't always want to go to physical
therapy. It's time consuming.
It is hard to get off of work.
Sometimes the hours are tricky,but in all the patients that I've had
go and they've been very happy with itbecause they have been able to see the
gains that they can make and the stridesthe physical therapy can actually provide
in a lot of these general shoulderconditions.
(08:32):
At what point would you order up imagingand what kind of imaging would be
necessary for you to say to apatient that they need arthroplasty?
So I always start with x-rays. Ithink when you have shoulder pain,
it's always important tohave x-rays because you never
find and there are a lot of differentvariants that you can see that can lead to
different types of shoulderissues. What I typically do,
(08:55):
I base a lot of these off x-raysand if we're looking at shoulder
arthritis in general,an MRI is really helpful and it shows
us if the rotator cuff is of goodquality. As we mentioned, the rotator
cuff's important to move the shoulder.
If we're going to do astandard shoulder replacement,
you need to have a really goodrotator cuff. So in general,
(09:18):
I look at advanced imaging when we haveno longer responded to conservative
management like physical therapy orinjections and we're looking to see if we
want to go down a surgical route.
So really I use MRIs for patientswith standard arthritis just so I
can see the quality of the rotator cuffand make sure there's no surprises.
(09:38):
What are you exactly looking for?
So that's great. So I look for tears.
I look to see if the qualityof the rotator cuff tendon
especially over certain ages,can have underlying tears that they
never knew about just from the wear andterror of life.
So those are things that I look for tomake sure that we don't have an increased
risk of the implant failingat a sooner period of time.
(09:59):
Other things I look for is I look forlittle fluid collections that you can see
in the bone called cysts and look tosee how good of a quality the bone is
because these are also things thatwe want to look for whenever we do a
surgery.
We want to maximize the chances of thisbeing the last surgery anyone's going to
ever have. And I think themore information we have,
(10:20):
the better so that we improve the ratesof having the most successful outcome
possible. Do.
You ever get in and youlook at the imaging and find
shoulder at all, thatthey have shoulder pain,
but it is not even the shoulderthat is causing the pain?
I see that every day. It's.
Usually the culprit. What is.
So that is an excellent question.
(10:41):
Oftentimes what can happen is patientscan have pinched nerves in their neck and
when you have a pinchednerve in your neck,
a lot of times it gives you pain thatcomes down your arm into your shoulder and
it makes it feel likeyou're having shoulder pain,
but it's actually coming from your neck.
Ways that we can kind of help identifythat is a lot of shooting pain that kind
(11:01):
of goes up into your neck, numbnessand tingling that shoots down your arm,
pain that comes down past the elbow.
These are all indicators a lot of thetime that patients have a pinched nerve in
their neck.
And that would probably reallybenefit from physical therapy.
Absolutely. So physical therapy,we have a lot of great spine doctors
here at MedStar and I have a lot ofcolleagues that I'll refer some of these
(11:25):
patients to so that we can maximizetheir outcome.
Okay. So you see that the rotatorcuff is in fair condition,
but there's minimal cartilage and thatthe patient has a lot of pain and you
know that they need anarthroplasty. How long do they wait?
What's the right time for that surgery?
(11:46):
There's a lot of things thatwe kind of factor in there.
One is how bad the arthritis is.
I have a lot of patients that come inand their arthritis is not that bad.
It just gives them a little bit of painhere and there and they're not ready for
a surgery. And in patients thataren't ready for a surgery,
I don't force it on them.
My job is to give the risks and benefitsof all options and to help the patient
(12:08):
make the best decision thatthey feel is they can make.
So one of the other things wekind of look for sometimes age.
I do have a lot of young patientswith pretty bad arthritis,
which is a little rare,but the thing is implants are not
meant to last a hundred years,so we have to factor in lifetime when
or basically number of years whenwe look and see what implants we're
(12:30):
going to use or when we're going to do anarthroplasty. But it is something
that we take into consideration.
That being said,I do have a lot of young patients that
have had great outcomes from shoulderreplacements.
Isn't that interesting because you wouldthink that by the time the joint wears
out, the patient would bemaybe in their seventies,
but I have read thatthey're getting younger.
(12:51):
Is that because maybe of sports orplaying year-round sports or I don't know.
Athletics?
That's a really good question.
There's a number of conditions.
I will tell you that with moreand more high contact sports,
their rates of dislocationsin shoulders has increased.
Sometimes when you haveshoulder instability where
(13:12):
out, it can increase your risk ofdeveloping arthritis and sometimes,
sometimes certain procedures that areintended to stabilize the shoulder can
result in patients getting arthritisat an earlier age than normal at a
sacrifice of having a more stableshoulder at a younger period of time.
In addition to that, some people justhave a higher predisposition for it.
(13:35):
Some people have very tough manual laborpositions that put you at a higher risk
and some people just havegenetic conditions that
risk of needing a shoulderreplacement. I mean,
there's just a lot ofthings that can drive it.
I mentioned that thetechnology has just advanced
strides in shoulder replacement.
(13:57):
I know it has in the past 20 yearsthat I've been here working at MedStar
Health. Let's talk about that.
Let's talk about the advancements andyou mentioned the reverse shoulder
replacement, which is an amazingkind of reconfiguration of what
nature created,taking the ball and make it into a socket
and taking the socket and making itinto a ball.
(14:18):
Who exactly would benefit from that kindof change in the anatomy and what is
the end result for that? Do the patientsstill have the same kind of motion?
So historically,the best patients for the
reverse replacement were tear.
They could not be repaired or those whohad such bad rotator cuff tears that
(14:38):
they started to have different changesto their joint that couldn't be treated
with a standard shoulderreplacement. That is still the case.
Patients that have rotator cuff tearsthat we can't fix a lot of times can
benefit very much from a reverseshoulder replacement. However,
there have been more and more studiesrecently that show that you can do a
reverse shoulder replacementfor conventional arthritis too,
(15:00):
and patients still have excellent rangeof motion and they have excellent pain
control. So it really kind of varies.
Now you can actually utilize a reverseshoulder replacement for a number of
things.
I am very selective in when I use ananatomic versus a reverse shoulder
replacement,but the indications for them have
been increasing significantly.
Why might you use that if theperson's rotator cuff was fine,
(15:24):
why might you opt for areverse shoulder replacement?
So one of the things that you look forwith a standard shoulder replacement is
you want to make sure that the socketcan sit well or the piece or the material
we use to recreate the socketcan sit well in the bone.
Now in some of the patients,they have different types of
wear or erosion of the socket,which makes it challenging to get
(15:46):
good coverage of the new socket.
And if you don't have good seeding of it,it can result in early failure or if you
have different degrees that the socketis tilted, that can also make it
challenging and result in early failure.
So in patients like that,we typically tend to go to a more
constrained device such as the reverseshoulder replacement is it's more
(16:08):
predictable, you have better coverage,lesser chance of there being failure from
essentially the piece of plastic thatis not seated very well in the bone.
So we really look at the glenoid side orthe socket side when we're making these
decisions and make sure that we can puteverything in the best way possible.
Is it different in terms of the lengthof the surgery or how big the incision is
(16:32):
or the recovery?
So the length of surgery isabout the same for both of them.
I would say the incision is theexact same incision for both of them.
Which is about how manyinches would you say?
It's about four to five inches.
Four to five inches front of thepatient's shoulder, front of the shoulder,
(16:52):
kind of coming from just kind of insideof the shoulder up top down to the mid
level of the arm bone.
Okay.
And then after the surgeryand the recovery processes
be different? And getting back to thatquestion, do they have the same motion?
So the recovery period is pretty similar.
We typically start patientswith range of motion early on,
(17:13):
but there is a period of time wherethey're in a sling. For my patients,
I have them in a slingfor about six weeks.
I start assistive range of motionearly on for about six weeks.
After six weeks we startdoing active range of motion,
removing the arm on its own at threemonths we start doing strengthening at six
months. There's kind of fewerrestrictions in terms of range of motion
(17:37):
in general, both surgeries, the range ofmotion is great. Patients do very well.
It has been my experience.
I think that patients with anatomicshoulder replacements get a little bit
better internal rotation,so reaching up their back.
But in terms of forwardelevation and external rotation,
if the rotator cuff is intact,there are great studies that show that
both types of replacements can result insimilar outcomes.
(18:03):
It kind of just varies on how muchof the rotator cuff is intact.
Okay. Let's get to the next advancement.
And that's stemless shoulder replacement.
Can you explain what that is?
Sure. So shoulder replacements,they conventionally have had
a stem, which is just a long,it's a long part of the metal that
goes down the center of the tube,which is the canal of the humerus.
(18:28):
And in the past allimplants have had that,
but more recently we'vedeveloped stemless,
which is a smaller componentthat actually is bone preserving.
So it actually results, ifyou ever need another surgery,
it makes it for a much easier procedure.
There's less bone that needs to beremoved and it's really quite fascinating.
(18:49):
It was mostly used in anatomictotal shoulder replacements,
but we're currently in a few governmentstudies now looking at its use in
reverse.
How does that benefit the patientand why would they want that?
I think one of the ways that it benefitsthem is that it's bone preserving.
If you ever need anothersurgery in the future,
(19:10):
it makes for a significantlyeasier procedure or a less complex
procedure. One of the issues issometimes when we do these procedures,
it can result in significant boneloss if they need to be revised.
The other thing is that sometimes patientshave a lot of deformity from prior
fractures and that can make it reallychallenging to put a stem down,
(19:31):
a not straight bone.
But with a stemless procedureor stemless implant,
you can really tailor thatto the patient's anatomy
you can do with what you have.
How does it hold onto the boneif it's not hammered into that
implant and that stem gethammered into that bone?
So I'm wondering how theSTEM was would even hold on.
(19:54):
How secure is it in your body?
I'll tell you, it is very secure.
There's different types of metalmaterial that we use. They can be porous,
they can have little grip blasting,but essentially the bone can form on
and inside of it and it kind of formsaround it and kind of incorporates
it into it. And it is quite strong.
(20:14):
I tell you, they get such great fixation.
And there's nothing thatwould be different in putting
what the patient needs to know andmanaging their expectations about the
surgery, the length of thesurgery or the recovery.
Getting a STEMIs doesn'tchange anything for them?
No, it does not. I've actually foundthe surgeries are a little bit faster,
but it's not significant. Andin terms of their recovery,
(20:38):
it does not have any impact.
Oh, okay. Alright. Whatabout 3D templating?
I think 3D templating is fantastic.
It is that we utilize to helptailor the procedure so that it is
the most specific for each patient.
And what that is is when wedo shoulder replacements,
we have patients get CAT scans.
(20:59):
And what that does is it allows us tolook at the bones and what worth two
dimensional views and we can convertthem into a three-dimensional view on the
computer and we can then planthe surgery specific to the
patient's anatomy so we can reallytailor this as much as possible so that
each patient gets the mostspecific accurate surgery possible
(21:22):
directly related to their own anatomy.
So it's for planning?
Absolutely.
Planning.
You're not looking at a 3D templateduring this actual surgery or just using.
For planning? So what we use it forhere is that we use it for planning.
There are some companies that do havemixed reality glasses that you can use
them in the operating room and that'sa really interesting area that we have
(21:46):
been looking into moving forward,but that is one area of advancement,
but currently we'reusing them for planning.
I know we used 3D printing ona tus bone that was replaced.
Very cool technology.
It is pretty cool. And I'll tell you,so we actually do a lot of
custom shoulder replacements.
Patients where there's so much bone lossthat conventional implants don't work
(22:09):
and we actually work with certaincompanies that 3D create certain
implants that will fit into those defects.
And apart from just 3Dtemplating on the computer,
we can actually design implants thatwe've used in individuals and we can
also design different models so we cansee how our implants will fit in the
(22:29):
patient. And that's anotherunique thing that we do here.
That is very cool.
The implants that we've been talking aboutused in shoulder arthroplasty are all
different. What do patients need to knowabout them? What makes them different?
What makes them better? Should theyask their doctor for anything specific?
How would they know what to ask for?
I think ultimately whenyou're looking at a shoulder
(22:52):
replacement,the biggest thing is that you want to
have trust in the person who's doing itand you want them to use the implants
that they are going to do the best job foryou. However, there are very
interesting technologies that are out.
One of the things are we havehighly cross-linked polyethylene,
which is a specifically manufacturedtype of plastic that we use.
(23:13):
And then when it's alsocoated with vitamin E,
it is something that myself and theshoulder division here we are very
interested in using because we believethat it has lower rates of wear
and creating issues forpatients down the road.
That's one thing that we typically use.
The use of pyro carb or useof hydrocarbon in shoulder
arthroplasty is of another in interestingfeature that we utilize here as well.
(23:37):
It's a different type of material thanthe conventional metals that are used in
standard shoulder arthroplasty.
It's kind of a material on bone andour goal is that it decreases the
risk and the rate that you have whereand needing another shoulder surgery in
the future and that is something thatwe certainly utilize here at MedStar.
(23:59):
I think ultimately though,when you're looking at these,
I think it's always importantto ask what implants the
surgeon uses if they use anything new orinnovative
and if they have experiencewith 3D templating.
I think 3D templating is fantasticand I think everyone should use it.
(24:19):
What should patients consider whendeciding on a shoulder surgeon?
Maybe they don't have one already orthey haven't been referred to one and the
shoulder program.
I think one thing is that you certainly,and there have been
studies looking at this,but you certainly want to go to somebody
who does a lot of shoulder arthroplastyif you have individuals who
do maybe five or 10 a year.
(24:43):
I think that the experience is not quitethere as much and I think that there
are certain differences thatyou can see in outcomes.
So I think volume is certainly asignificant thing that you need to ask.
I think duration of time,number of cases are
all important features.
And then I think philosophy too.
I think it's always really importantto understand what everybody's
(25:06):
postoperative procedures are,how they take you through
the postoperative period,what the hospital stay is like.
There's a lot of really unique thingsthat we do here that I think really show
in our patient satisfaction,but I definitely think you need to be
pretty selective when you're deciding whoyou finally go to have
(25:26):
your shoulder replaced.
Well, to that point,Helio published the results of a study
that showed total shoulder arthroplastyperformed by a high volume surgeon
may decrease medical and surgicalcomplications compared with those
who performed lower volumes.
Should patients ask how many totalshoulder replacements a surgeon has done
(25:47):
during a consult, would you be offendedby that question? As a surgeon, I.
Would tell you I don't think I'moffended by any question I get asked.
You never know whatyou're going to get asked.
Good to know.
I'm an open book. I answerall questions that are asked.
So I personally am not offendedby anything that is asked,
especially when you're making such animportant decision as to having a part of
(26:08):
your body replaced.
It's very personal decision and I don'tthink that anybody should be offended
when somebody's doing their due diligenceand trying to do their homework and
make sure they make the bestdecision possible. I mean,
especially when there's so manypeople that dabble in different areas,
you want to make sure that you go tosomebody who's really comfortable,
who does a lot of them and who can giveyou the outcome that you're looking for.
(26:33):
What would be a lot of them, what wouldbe a good number to make you feel safe?
I would say you want somebody whodoes at least 50 to a hundred a year.
Okay. With all the changes we've alreadyseen in the advancement of shoulder
arthroplasty, what do youthink the future holds?
So I think that's a really great question.
I think one of the things that thefuture holds is robotics and shoulder
(26:56):
surgery.
We've already seen great success withthat in total hip and knee surgery,
and we have more and more areas where wecan use robotics and shoulder surgery,
especially with shoulderreplacements Here at MedStar,
we actually have the technology for theseand this is definitely an area that we
are working towards implementingin our regular practice.
(27:17):
How would that work? Actually,to tell you what angle to put the
implant in or to put a screw in,I am thinking in terms of how it
works for other orthopedic surgeries.
I think one of the ways that people haveutilized or one of the ways that people
have utilized it are making sure that wemake perfect cuts when we make our cuts
for the humerus or puttingthe implants into the socket.
Sometimes the deformity that you cansee in the socket can be a little tricky
(27:40):
and unless you do a lot of them,getting certain trajectories can be
a little bit challenging for some.
And what robotics allows us todo is to be extremely accurate to
make sure that we don't have any issuesto make sure that the implants are
placed and all of the cuts are madein the most perfect way possible.
They kind of take out a lot ofthe guess and check aspect of it.
(28:03):
We've been talking with MedStarHealth Shoulder and elbow surgeon,
Dr. Ryan Hoffman.
Thank you for sharing your expertise withus here on Doc talk for an appointment
with Dr. Hoffman off4 1 0 5 5 4 2 2 7 2.
If you would like to share feedbackon this podcast or suggest a topic for
another episode ofMedStar Health Doc talk,
(28:24):
send me an email Deborahschindler@medstar.net.
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