Shoulder Arthritis and Surgical Interventions with Associate Professor Mark Haber

In this Podcast, Associate Professor Mark Haber, a distinguished shoulder specialist, presents a comprehensive overview of shoulder arthritis, its implications, and current management techniques. With an impressive background that includes over 2,000 shoulder arthroscopies and being at the forefront of advanced surgical techniques, Dr. Haber shares his insights on how arthritis uniquely impacts the shoulder, detailing the critical relationship between rotator cuff tears and osteoarthritis, referred to as rotator cuff tear arthropathy.

Dr. Haber begins by addressing common shoulder conditions, emphasizing the profound effects arthritis can have on patients' lives, particularly when it comes to sleep quality and physical activity. He notes that shoulder pain often has a more significant impact on quality of life than pain from other joints due to the shoulder's complexity and mobility. The discussion progresses to the anatomical peculiarities of the shoulder joint, highlighting the role of the deltoid muscle and the rotator cuff tendons in maintaining shoulder stability as well as their mutual dependency.

The lecture dives deeper into the diagnostic aspects, where Dr. Haber critiques the traditional use of terms like "bursitis" and "frozen shoulder," suggesting they may hinder accurate diagnosis. He argues that a detailed examination and appropriate imaging, particularly X-rays, are crucial for identifying the prevalence of specific conditions such as cuff tear arthropathy and osteoarthritis. Emphasis is placed on the nuance of interpreting MRIs, with Dr. Haber pointing out the common misconception regarding age-related changes, especially concerning acromioclavicular joint arthritis.

As he transitions into treatment management, Dr. Haber states that accurate diagnosis precedes intervention, outlining the importance of patient history and physical examination. Non-operative management strategies are explored, including medications, physiotherapy, and injectable treatments like cortisone, with a focus on ultrasound guidance for accuracy in injections. He also stresses that while physiotherapy has a role in shoulder management, particularly in mild cases, its effectiveness in severe arthritis cases is limited.

With a significant portion of the lecture dedicated to surgical interventions, Dr. Haber elaborates on shoulder replacements, specifically highlighting the revolutionary impact of reverse shoulder replacements. He explains the rationale behind this design, which improves stability by counterintuitively switching the positions of the ball and socket in the joint. The benefits of this approach are substantiated by data from the Australian Orthopedic Joint Registry, showing superior long-term outcomes compared to traditional anatomic replacements.

Finally, Dr. Haber addresses postoperative care and rehabilitation, detailing innovative approaches that allow for faster recovery and return to daily activities and sports. His findings indicate a high level of satisfaction among patients post-surgery, with the majority able to resume recreational activities and even athletics within months. The lecture concludes with a call to reconsider and refine current practices in diagnosing and managing shoulder arthritis, advocating for a more nuanced understanding of shoulder anatomy and pathology to enhance patient outcomes.

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It is my pleasure to introduce Associate Professor Mark Haber.

He's an experienced and highly skilled shoulder specialist.

And Dr. Haber uses the latest shoulder arthroscopy and techniques to address

shoulder pain and rotator cuff tears.

He's performed over 2,000 shoulder arthroscopies during his career.

I'd say plenty more than that now. This is an old profile.

And continues to pioneer advanced techniques due to improve surgical outcomes

and reduce recovery times.

Dr. Haber is honoured to have been the first surgeon in Australia to perform

a computer-assisted shoulder surgery in Sydney in January 2017,

so a very historic move, Haber.

And he's renowned among his peers and is recognised as a pioneer of shoulder

surgery, teaching, and advanced arthroscopic techniques to shoulder surgeons

and shoulder specialists across Australia, Asia and Europe.

So thank you very much for speaking today and I hope you'll see you.

Okay, so thank you very much for the introduction, and we missed the first slide,

which is reminding me to thank you, all you guys, for missing your day out in

the beautiful sunshine to spend there with us, so I hope we make it worth your

while, so thank you very much for coming. I really appreciate it.

And the topics I've been told to cover is how did arthritis affect shoulders,

when to refer, how do we assess, what can be done to reduce pain and surgical intervention?

So I'll try and cover those. I don't think I've got any particular disclosures, but on location.

So anatomically, I'm very, very, very specific. I only do elective shoulder

surgery. I only do four operations.

So I'm geographically a bit more spread. Outside of Macquarie,

I also consult out of Wollongong, Sydney CBD, and also in Campbelltown.

So when we look at common shoulder conditions, I'd love to discuss them all.

But really, when we talk about rotator cuff tears and osteoarthritis,

they're very closely interconnected, something called rotator cuff tear arthropathy,

which is the majority of people with arthritis.

So how does arthritis affect shoulders? It's a bit unique.

I started looking at a clinical course of shoulder pain. Basically,

the three worst symptoms were they sleep less well,

they're less physical recreation, and the combination of that makes a more irritable,

huge impact on their quality of life.

And because shoulders more than hips and knees affects their ability to sleep,

it probably has a more profound effect on quality of life, not just activity.

Now, we'll talk more about MRIs and what is arthritis, but generally there's

the shoulder joint, but you've got to be very careful with MRIs because they

always report acromioclavicular joint arthritis. They'll never just say it's normal.

Now, the unique thing about shoulders is it's the most mobile joint in the animal kingdom,

but is also the most unstable joint in the animal kingdom because the ball is

a decent ball, but the socket's almost completely flat, and the deltoid is the

powerhouse which moves the shoulder.

The deltoid spreads, covers the shoulder from front to middle to back,

and it is the powerhouse of the shoulder joint, which introduces unique issues,

which we'll discuss as we go,

because as you know, the rotator cuff in the front subscap,

in the top supra, in the back infraspinatus, it's the rotator cuff that holds

the ball in the socket and always has to fight against the deltoid.

So you've got the deltoid which cloaks it. The deltoid lifts the arm up,

but it's the rotator cuff which holds it down.

And as we said, the deltoid lifts the arm up. The rotator cuff,

like your sleeve, is a cuff.

It surrounds the shoulder joint. They're not independent tendons,

as opposed to this model.

So when the deltoid lifts it up and the shoulder moves around,

it's the bursa that lies in between that lubricates it all. You've got to be

careful because every investigation under the sun always says there's bursitis.

Now, not everybody on the planet has bursitis. It's a meaningless term. It means nothing.

What is bursitis? I could dedicate an hour's talk just on that alone.

Now, the unique thing about rotator cuff tendons, which is not true for hips

and knees, is they wear out.

Now, that's unique. So in the shoulder joint, what wears out,

it's the tendons and the joint. So they can do it together or they can do it separately.

Now, but they tend to do it together. The tendons tend to fail,

as does the joint fail. And it's a term called a calf tear arthropathy.

So when the tendons fail, you get superior upward migration of the humeral head,

which is very, very common in arthritic patients to varying degrees and completely

has changed the way we manage shoulder arthritis.

Due to the gross instability and the reliance on the tendons.

So this is an example of an x-ray where you can see that the humeral head is

sitting on the acromion and the glenoid is grounding through the humeral head.

So it's a unique thing. Cuff tarotrop is a unique thing which is very dissimilar.

From the hips and the knees.

So just last week, we CT navigate all our shoulder placements.

And I just had a patient last week where I saw it was a classic.

You can see the ball looks all right. The head looks kind of all right,

but you can see the ball doesn't sit in the socket anymore.

So this is a really typical example of a cuff tear arthropathy where the humeral

head's grinding on their chromium and not sitting properly in the glenule anymore.

So that's a cuff tear arthropathy. And these massive tears are often associated

with what we call pseudoparalysis, secondary to a massive rotator cuff tear,

but it's not a neurological lesion, but it does have the equivalent.

They can't raise their arm, even if they've got range of motion.

I use an allergy, it's the toe bar of your car.

You need a stable ball and socket joint for the shoulder to work properly.

The deltoid lifts the shoulder up. It's the humeral head that holds it down

so that you've got stability, so they get what's like a non-neurological paralysis.

Now, in terms of ongoing management, it's all about diagnosis.

So it's all about the horse before the car. You have to make a diagnosis before

you manage patients because in shoulders, I think it's a much more complex diagnosis.

And we see so many errors in management, not by GPs, of course,

where, for example, I've seen another patient last week had a year of physiotherapy

for a frozen shoulder, and they had arthritis.

Now, a year of physio, and we see that a lot. So how do we diagnose shoulder

arthritis? Again, it's unique.

Glyner-humeral instability for young people, and as you get older, it disappears.

Capsulitis is almost unique in their 50s. So when you say it's a frozen shoulder,

it's almost unique in their 50s.

It rarely occurs outside of that age group.

But rotator cuffs just wear out with age, as does the shoulder joint, just wears out with age.

But the unique thing about pure osteoarthritis tends to be 10,

20 years after hips and knees.

So when they're pure arthritis, tends to be much older patients in their 70s

plus. So totally different populations.

So when we diagnose, we've got to examine the patient, and the tradition is to look, feel, and move.

But the challenging issue in the shoulder is you can neither see nor feel anything

because the entire shoulder is cloaked by the deltoid.

The only thing you can actually feel is the AC joint, which you'd possibly argue

is not even the shoulder joint.

But it's the only palpable structure of the shoulder joint is the AC joint.

All the other intra-articular structures, labrum, capsule, biceps,

you can't palpate them. and the patients say their shoulders always click,

it doesn't really help us make the diagnosis.

So unless they localize and you've got localized AC joint, then the touching

doesn't help. But the range of motion really does help.

Forward elevation, external rotation, internal rotation.

If they've got a global restriction range of motion, they tend to be tagged

to have a frozen shoulder. And a frozen shoulder means nothing.

It means they're stiff and sore. So the general trend or the recommendations

is that frozen shoulder gets chucked in the bin. It's a useless term.

But if they're elderly, it's not a frozen shoulder.

Think arthritis. If they're stiff and sore and they're elderly, think arthritis.

And as has already been discussed earlier today, you know, sometimes they just need an x-ray.

It can be diagnostic. But if they're elderly with rotator cuff tear,

it's still worth getting an x-ray because they can have cuff tereflopathy,

upward migration of the humeral head, arthritis, as well as rotator cuff tear,

because in the early, it goes hand in hand.

And osteoarthritis x-rays are totally diagnostic, so you don't need MRIs.

So this is what a normal x-ray should look like. A beautiful humeral head,

a beautiful glenoid, a gap in the middle, which is the joint space,

and a gap between the acromion and the humeral head, roughly between 7 and 13 millimeters.

But if the humeral head's touching the acromion, they've got a massive cuff

tear. They've got a cuff tear arthropathy.

So here's a normal x-ray as we've shown.

Early arthritis, where you see a spur. Severe arthritis, when you see gross

destruction of the joint.

Now, the spur of the shoulder joint has got a unique name. It's called a goat's beard.

Oh, it didn't go. Where's my

goat? There's the goat. It's called a goat's beard, and it's the big clue.

So if they've got a goat's beard, they've got arthritis. So sometimes when they've

got very mild arthritis, the only thing they've got is a goat's beard.

The joint looks perfect. But if they've got a goat's beard, that's the clue

that they've got arthritis.

So if they're complaining of pain, get a plain x-ray.

They've got a goat's beard, they've got arthritis. Sometimes it's severe,

but it can be quite subtle.

With cuffed arthropathy, again, you see upward migration of the humeral head.

That's the glenod and the acromion where the humeral head's gliding on,

but they've got their little goat speared.

So they've got not just a massive tear, they've got a true cuffed arthropathy.

And this is just an example of a severe case of upward migration of the humeral head.

They're roting their acromion, they're upward migrated, they've got a spur.

Classic severe cuffed arthropathy. And as discussed earlier today,

the role of an MRI, you don't need an MRI.

And again, the patients hate it, especially in the shoulder,

because they're head first in the machine, and they hate that.

In the rotator cuff, only when it's severe do we ever get an MRI.

Osteoarthritis, there's really no point.

There's no point. But the careful thing about MRIs is every time you get an

MRI, every time, they'll say there's AC joint arthritis.

And the number of patients sent to our rooms with AC joint arthritis,

they'll never say that it's a normal age-related change because everybody in

the planet over the age of the 60 has got an abnormal AC joint. That's normal.

So that's not where the pain's coming from.

So the MRI can show lots of other things.

We don't have time to talk about MRI, but really shows a lot of things in the

shoulder joint that an x-ray would have told us anyway. So there's really no point.

Cuff to arthropathy, we do get MRI if we're looking at only cuff repair,

not replacement, because it shows there's a retraction of the tendon and all

the other arthritic changes.

So we only do that if we think it's a cuff tear that needs to be fixed, not arthritis.

And the other thing we see is what's called the Y view on the MRI.

We can see what the normal muscles should look like.

And this is what a cuff tear arthropathy looks like, where the muscle has degenerated away.

You can see the size of the muscle, it's only tiny, and in the infraspinatus,

it's half full of just fat. The muscle's gone.

So as cuff terarthropathy deteriorates, the humeral head rides up,

and both head and glenoid show the destruction of arthritis.

CT, that's an example of what a CT looks like, but there's really no point in diagnostic.

We get CT on all the patients who need shoulder replacements because we do navigation,

but it plays no role in arthritis unless MRI is contraindicated.

So now that we've made the diagnosis, how do we manage it?

So once we've got the diagnosis, we can then plan the management.

Our non-operative things are medications, physiotherapy.

Now, medications, you know way more about it than I do. I won't comment.

Physiotherapy, the physiotherapist isn't here, so I hope I don't offend anybody.

And of course, injections play a huge role. and they almost,

I would say they have to be ultrasound guided and we'll talk about that.

Now lots of studies on physiotherapy management with shoulder arthritis as opposed

to what we've heard earlier today, a study in 2023 looking at physiotherapy with osteoarthritis.

What they looked at is the pre-op, the non-operative instead of shoulder placement.

Post-op, that the quality of evidence is totally insufficient and the strength

recommendation is one out of four.

So while I'm a great fan of physiotherapy for everything else in the shoulder

joint, it doesn't really have a role just in osteoarthritis.

It doesn't have much role.

We'll talk about it. But another study looking at 2 million people in the US at 24 only last year,

concluded that individuals who had physical therapy as part of their non-surgical

treatment did not have any decrease in the probability of requiring a shoulder replacement.

So it doesn't actually change the inevitable.

And another study in 23, two years ago, concluded there is some small but statistical

significance of only short-term improvements in pain range of motion disability,

but only in patients with mild arthritis on x-rays.

So there is a role, but it's only a small role and doesn't change the natural history.

Now, the other things are injections, which we've got PRP, hyaluronic acid, and cortisone.

And this is a huge pet interest of mine, which I'll explain,

again, because it has to be ultrasound-guided, I would recommend.

Now, the injectable biologics, I'm sorry, stem cells and platelets cannot be

recommended in glenohumeral joint arthritis.

There's no paper that supports that 2020 report.

Hyaluronic acid also strong evidence supports there's no benefit of hyaluronic

acid in glenocumeral joint arthritis.

15 years ago, I used to do knees and we used to do heaps of hyaluronic acid

injections. I had a lot of faith in that, but just doesn't seem to work with shoulders.

Now, steroid injections are one of the most effective treatments.

Works as a powerful anti-inflammatory, reduces swelling, pain,

and improves mobility in some people only.

But it's all about where to do the injection, which is why we have to make the

diagnosis. because in the shoulder joint, we've got the bursa,

we've got the AC joint, we've got the glenohumeral joint, which also runs down

into the long-headed biceps tendon.

So in the shoulder joint, the joint itself and the bursa are two completely

separate cavities if the rotator cuff is intact.

If the rotator cuff is not intact, they're one cavity.

But if the rotator cuff is intact, they're two cavities. You have to inject

the right spot, which is why diagnosis really helps.

So we'll talk about cortisone injections. I do a lot of them.

I always warn patients, they do get a temporary soreness. It flares them up

for 24 to 48 hours, and that's just normal and common and does resolve.

But I warn them they should probably increase their analgesics for a day or

two after the injection.

Fortunately, the risk of infection, as we talked about, is extremely rare in shoulders.

I touch wood, extremely rare. Now, about bleeding and bruising,

which can occur with people on blood thinners, if they're on a Paxibane,

it'd be nice if they could stop it for a diet too.

But if they need to be on the aspirin, I don't think that's a contraindication.

And we do a lot of, we inject them. If they're on aspirin, we don't worry about it.

Allergic reaction is uncommon, but it's nice to know if we get referred patients

if they have an allergic reaction.

Diabetes is a big thing. Thank you.

We've had a few patients who end up in intensive care after a cortisone injection.

So we give them a smaller dose. We do a test. I tell them to monitor their sugars.

It's very important if they're diabetic because we do a lot of cortisone injections

and it's very important.

They do also complain about facial flushing, mood changes, and insomnia after

a decent dose of cortisone.

So again, we just warn them that's just normal.

The long-term effects, okay, there's cartilage damage and tendon weakening.

But if they're going to have a joint replacement, I guess that doesn't really matter in the long term.

So I've warned them about the time frame. Local anesthetic, they feel better.

Oops, I've got to keep moving.

Anyway, let me talk to you about ultrasound.

Now, the thing about ultrasound, I've worked with sonographers for 15 years.

I never consult without a sonographer.

So we work together, as I said.

And when we do cortisone injections, especially in the shoulder joint,

we've got to work with a sonographer to make sure they track the needle so we

get the right spot and we watch the needle go into the shoulder joint

and we watch the fluid from the cortisone flush through the joint so we get

100% confident we got the right spot because it is a test.

Now, sometimes they're done to CT, they don't have time to talk about it,

but CT, I think, is very uncomfortable.

Patients hate it. I think it's totally unnecessary. So when to refer to an orthopedic

surgeon, well, I'm happy to do injections you can refer to as we always do it.

I'll skip through the cortisone because I want to talk about shoulder replacements.

The indication of shoulder replacements is pain and impact on quality of life.

Now, let me talk about reverses because it's quite a quirky thing.

When we do a reverse replacement, we change the head for head,

socket for socket, and it's like a golf ball sitting on a golf tee.

As I said, the most unstable joint in the animal kingdom, an anatomic replacement

has the issue that it is intrinsically unstable.

So when you raise your arm up with your deltoid, again, as we talked about,

you're relying on the rotator cuff to hold the ball in the socket.

If the cuff fails, the replacement fails.

So some 20, 30 years ago, they came up with the concept of providing stability.

So that's the instability of an anatomic, what we call an anatomic.

When the cuff fails, when you raise your arm, your replacement fails.

It subluxes, and we see that heaps of times. They tried to make the socket better,

didn't work, didn't provide the stability.

So that's what an anatomic looks like, intrinsically unstable.

So they came up with a concept 20, 30 years ago of trying to make it more stable.

Unfortunately, they called it a reverse. So you put a socket where the ball

is, you fix the ball where the socket is, and a poly in between.

And so when you lift your arm up, it's totally stable. And this is an example, so animation.

So where we show the shoulder is intrinsically unstable, the deltoid is always

fighting against the rotator cuff.

Unfortunately, the deltoid wins and the cuff fails in almost everybody.

So you get upward migration of

the humeral head. So they came up with a concept of fixing this problem.

You put a ball where the socket is, you put a sock where the ball is,

and it's grossly stable.

The greatest advance in shoulder surgery. There's only one problem.

This is an example of what it looks like.

When you flex your deltoid, it's a stable joint, it stays.

You can see the humeral head is depressed down and it stays there.

It is way more successful.

The problem is why call it a reverse?

Patients freak out when you say we're going to do a reverse because reverse

in English means we're going to do it backwards and they feel they're going to end up backwards.

But it's all about stabilizing the ball and socket by swapping over the ball and socket.

So unfortunately, I always warn patients. It was a French biomechanical engineer

who came up with the name, and it freaks people out. I warned them,

we're not going to go backwards.

We're just going to swap the ball and sock it over.

And that's why it's called reverse, anatomic versus reverse.

And you can, so the Australian Orthopedic Joint Registry is very interesting.

As you can see, there are 58,000, 78,000 knees, only 10,000 shoulders done in Australia.

Of which the average shoulder surgeon, a general surgeon does five a year,

where they do like 150 other joints.

So I won't have time to discuss it, but that's why I think we've become dedicated shoulder surgeons.

I gave up doing these 15 years ago, just two shoulders, because studies have

shown that there are better results with your volume.

So when we look at the joint registry, we

have our reverses and anatomics the reverses are approaching 100% and the anatomics

are approaching 0% and that's because the anatomics have a much much higher

revision rate compared to a reverser which has got brilliant long term results

so that's why the trend has gone.

The anatomics have all these issues which I don't have time to talk about and

this is an example of anatomic that we see all the time it fails,

it subluxes We have to revise it to reverse, which lasts much longer.

So the introduction of a reverse shoulder replacement is arguably the greatest

advance in shoulder surgery in our working lives. We've come a long way.

So now the greatest advance, one of the greatest advances anyway,

is our preoperative planning. I use an analogy, it's like shoes.

We've all got different size and

shape. We've got to choose the right component to get the best results.

So these days we do a CT and we plan everybody. We pre-plan,

we put the implants, we decide what size and which shape will fit best.

Okay, and this is just an example of severe deformity, which we can address

now by pre-planning, choosing the right implants, we can correct deformity by

just taking different components.

So I'll skip through, but anyway, complication rates are grossly reduced by

the better position fixation of the glenone components.

And this is what we do for every single patient, which makes sure the shoulder

replacement works properly. I've got to finish off.

So the rehab's completely changed. Because we've got a more stable joint,

we don't need to keep them in a sling anymore while they're awake.

They can sit however they feel comfortable.

They start their own physiotherapy and are much more comfortable because of that.

The rehab I know I have time to talk about, but basically they start driving six weeks.

They can drive at six weeks. They can start swimming at six weeks.

They can start playing gentle golf.

They can swim at 12 weeks properly. So at six weeks, they start golf by eight

months. They're usually back playing competitive golf.

Now, in terms of returning to function, they can, as I said,

do general things at six weeks and get back to full activities by six months,

returning to work and things like that.

I'll skip through this. Crohn's stress fracture is a bit of an esoteric thing,

but just my last comment on return to sport, which is another pet interest.

We're doing research with medical students at Macquarie University Hospital,

looking at return to sport.

And as you can see, 66% of this study could get back to golf,

only 50% of tennis players.

In our study, we're currently doing with medical students. What we found was

90% of the patients were very happy with their operation.

66% were able to return to sport, of which 60 could, at the same or even a higher

level than before the surgery, 70% at golf, gym 85, gardening 83,

97 activities of daily living.

So really the results of reverse replacement have radically changed how we manage arthritis.

Thank you very much. I'm sorry. I've gone over a minimum of 50 seconds.