Panel Discussion AProf. Mark Haber, Dr Matthew White , Mr Jonathan Kuan

The podcast focuses on various aspects of shoulder and hand pathology, with Dr. Haber leading the discussion by addressing the rationale behind choosing anatomical shoulder replacements amidst a downward trend in their use. He highlights that while anatomical replacements offer better range of motion, they fall short in longevity, resulting in a low adoption rate within his practice. Dr. Haber emphasizes the complexities and controversies surrounding this procedure, noting that he primarily engages in revising anatomical cases.

A significant part of the discussion centers on thumb arthritis, triggered by a participant's personal experience. Dr. Haber and colleagues express gratitude for the insightful visual presentations on shoulder anatomy provided by their peers, which enhanced understanding of the deltoid and rotator cuff functions essential for patient education. The interaction highlights the importance of clear communication in medical practice.

The conversation then shifts to conditions such as tenosynovitis, trigger finger, and Dupuytren's contractures, prompting Dr. White to explain the distinction between Dupuytren’s disease—characterized by a fibrotic transformation leading to finger flexion—and tenosynovitis, which may be exacerbated by the presence of Dupuytren’s. The complexity of these conditions showcases the need for thorough understanding in both diagnosis and treatment. Dr. White elaborates on the common occurrence of trigger finger, often arising without a clear causative factor, and discusses the effectiveness of steroid injections during acute inflammatory phases.

As the topic deepens, Dr. Haber addresses the appropriate wording and specific views needed for shoulder X-ray orders, underscoring the need for clarity in medical documentation. The discussion transitions to Raynaud's disease, where Dr. Haber provides insights on therapeutic options. He recommends Maccuffre’s gloves for warmth and suggests that many patients manage the condition successfully through lifestyle modifications rather than through intensive medical interventions. He notes that in advanced cases requiring surgical options, evidence remains mixed, indicating that procedure effectiveness varies by patient and condition.

Shifting focus to dietary supplements such as turmeric and fish oil, Dr. Haber examines their debated role in managing inflammation and pain. He shares his perspective on the placebo effect associated with such supplements while acknowledging the growing body of evidence surrounding their efficacy. Emphasizing a cautious approach, he avoids recommending these supplements but remains open to patients trying them if they find personal benefit.

The lecture concludes with a consideration of topical treatments like Voltaren gel, which Dr. Haber believes may provide some relief through massage benefits and skin absorption, although he cautions against their impact on joint progression. Ultimately, the panel responds to a range of inquiries, reflecting a comprehensive engagement with the complexities of musculoskeletal conditions and treatment modalities. The discussion encapsulates a detailed exploration of both common and complex hand and shoulder pathologies, highlighting the importance of evidence-based practice and patient-centered care in orthopedic medicine.

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To Dr. Haber, is there any reason now why one would choose anatomical shoulder replacement?

That is such a good question. And as you can see in the trend,

anatomics are disappearing.

It's very controversial. So in New South Wales, 70% of replacements are over

30% are anatomics, where I would do about 1% of anatomics.

Because all I do is revise other people's anatomics.

Is there any reason to anatomics they do have a better range of motion but the

trade-off is less, it doesn't last as long thank you.

It's actually not really a question thank you for the presentations basically,

they were really good really enjoyed them I do have thumb arthritis myself,

So I'm very fascinated about all the, yes, all the exercises.

But actually, Mark, those pictures you put up of the shoulder demonstrating

the deltoid and the work that it does and then the rotator cuff,

I've got such a good visual now.

I'll be able to kind of explain better to patients and all the physios.

So I'm just going to say thank you for wonderful presentations.

Thank you for saying thank you. I appreciate it. Okay.

Dr. James, I'm very sorry. I cannot pronounce half the words in your question,

so I'm going to pass you the microphone.

Ah. Okay.

Um...

Could you discuss, well, perhaps this is inappropriate, but to discuss a little bit for Dr.

White, I guess, primarily, tenosynovitis, trigger finger, and Dupuytren’s contractures.

Yeah, sure. So my personal feeling is that Dupuytren’s and tenosynovitis are

two separate pathologies.

So we know that Dupuytren’s disease causes a flexural contraction,

but it's actually a transformation in cell type from a static fibroblast to

a myofibroblast, which has the ability to contract.

And that's in the parma fascia, which is superficial to the tendons.

You do get increased triggering, so flexotinocyanivitis secondary to Jupitrons,

and that's because some of the fibers of Jupitrons aren't just transverse.

There are fibers that come deep up from the palm and form cascades and arcs

over the top of the tendons.

So if you get Dupuytren’s contracture of those, they snug in around the tendon,

and the tendon starts to rub against

them, so you can get increased flexotinocyanivitis. sinusoidalitis.

So there is a higher risk of triggering in Jupyter's patients,

and that would be the reason why.

Triggering is really common. It can be there for a million reasons,

but most of the time we don't know why. Someone just gets their left ring finger

as opposed to 10 years ago their right index finger. It just seems to happen.

There's very rarely a story of, I did this and it caused it. It just comes on.

And when you operate on people, you often find that they've got a nodule on

the tendon, which has been there for a long, long time.

So that is chronic change, chronic scarring change within the tendon.

But you might catch people very early, and this is when steroids are most effective,

when they're in that acute inflammatory phase.

So the painful phase of a trigger, I don't really know what my hand doesn't

catch, but it hurts around the palm.

That's probably where they've got the acute inflammatory phase.

Steroids are good for acute inflammation. If they've got a lump on the tendon.

And it's actually locking i find steroids don't

really have a role to play it's very rare that you'll get someone unlocked

or someone that actually catches each time

to stop that with a steroid it can happen i've

had patients that do that that work on that do not

want an operation but simple surgery it's a

10-minute procedure to undo the a1 pulley it's day

surgery and people recover very quickly and from the second

you release it their symptoms have gone so surgery for

true locking is effective i give

steroids out a lot i inject them myself if people don't

want to spend the time with me i give them a form and they go off and get it

at their leisure and i would say if someone's having more than a couple of year

i say look it's time to do something and be a bit more permanent but i've got

a huge cohort of patients that just come for review get a steroid injection

i do it i'm probably cheaper than a ultrasonographer and radiologist i'll be honest.

And it's very effective, works very well.

So two different pathologies, but they can coincide because of one causing another.

But most triggering is not related to Jupiter.

Fabulous, thank you. Dr Haber, can you please comment on the appropriate wording

for shoulder x-ray ordering?

Are there any specific views that we request?

Ask Google, don't ask me. If it's just for arthritis, just x-ray,

you don't need to specify particular position for arthritis.

Thank you. Jonathan, what type of hand therapy and device or gloves can you

recommend for patients with Reynolds' disease?

Sorry, I don't know if I said that correctly. Reynolds' disease.

Reynolds' disease. Yeah, so Reynolds' disease involves sort of the coldness

sensation, bluing of fingers.

Maccuffre's gloves is commonly what I would generally prescribe.

Cheaper options can generally include a woolen glove.

But certainly with Reynolds require I would say I would further send them back

to their GPs for specialist review just to make sure that there are more deeper

underlying pathologies with that and to get them onto appropriate treatment,

to answer the question alone i've met imac authorized gloves i fried his gloves

or woolen gloves would be a good start yeah i mean most ray nodes is primary

ray nodes which is idiopathic we don't know why it happens but there are some

very rare causes of ray nodes paraneoplastic ray nodes,

secondary to injuries around the sympathetics in the hand most ray nodes can

be controlled without medical management at all.

So just patients be advised, don't go out in the cold, wear gloves in the cold,

warm your hands up at the start of the day or times that it affects you.

And most patients with that disease will get by just with that.

Those that do need interventions, the huge bulk of it is medical management.

I only really get involved in Raynaud's for very advanced Raynaud's that has

failed medical management.

So most patients I see that are on medical management is prostaglandins and

they work very well but there are some that that's resistant to,

so particularly perineoplastic ray nodes when they've had chemotherapy they've got a,

perineoplastic syndrome and they're starting to get ulcers on their fingers once

they start to ulcerate and they're failing medical management there are

surgical strategies which is basically a

sympathectomy sympathectomy in the hand is

a controversial issue i was just in washington last

week at the international hand meeting and there

was a whole session on this and basically by

the time I get hold of patients it's often because they're

failing medical management and they're losing fingertips and GPs

and rheumatologists are going it's not working I don't

know what to do next can surgery help and they're often referred

for an amputation so a sympathectomy can be useful but the evidence behind it

is variable because there's not a lot of these patients and so a lot it is retrospective

cohort studies rather than huge uh huge trials um prospective randomized there

just aren't that many patients with it that need the surgery,

But those that fail, you can do sympathectomy of the radial ulnar arteries and

in the digital, common digitals as well. And that can be very effective.

Thank you. And the last question for today, do you have any thoughts or comments

on supplements, for example, turmeric

or fish oil, regarding the impact on inflammation and pain for joint pain?

We're often asked about these supplements.

I was at GP Talk a couple of years ago, and one of the GPs there was obsessed

about it. And I was like, you know what? I should read up a bit more on this.

There are anti-inflammatory and nociceptive effects of a lot of chemicals and

paracetamols from woodbark.

So we've all got things from the natural world.

I'm a person that doesn't really rely too much on it. If someone says to me,

I want to try this, I'm like, as long as it's not costing you a lot of money

and if you feel it works, the placebo effect is huge.

If someone takes something and it helps, however, the evidence behind much of these is limited.

But it is growing. So some people are taking on certain ones,

but in hand and wrist, there really isn't a huge amount of evidence to say this supplement does this.

And most of the time, patients are paying a lot of money for supplementation

and it's probably a placebo effect.

So I never prescribe it myself. I never suggest it.

But if someone asks me and said, I've been taking this and I want to,

I don't think it's usually of harm as long as it doesn't cost them a lot of

money. That's my general advice.

The question was, what about Voltaren gel directly onto the joints?

Yeah, so again, it's probably the massage itself that's doing something.

So you're getting a thermo effect from touching.

You're also getting a proprioceptive pain blocking pathway from the actual massage

itself, as well as maybe some superficial anti-inflammatory effect.

I don't feel that that's something that's going to stop someone's arthritis progressing.

But again, if someone likes to do that, they're probably doing more than one thing.

They're paying attention to their arthritic joint they're doing some self-care

it's simple and cheap and I don't think it's a bad thing to do,

I don't know about shoulders it's not something that shoulders are a bit of

a bigger joint and deeper I'm not sure how effective they are exactly with the

shoulder joint the deltoid cloaks the joint so you can't get into it yeah,

ladies and gentlemen please thank our panel thank you.