The discussion focuses on the complexities surrounding shoulder surgery, particularly the use of reverse total shoulder arthroplasties (RTSA) for cases involving rotator cuff tears and related arthropathy. The speaker, Simit, explains that while reverse shoulder replacements are becoming prevalent, the indications for them are more nuanced than simply addressing rotator cuff damages. There is a noted increase in RTSA cases due to previous neglect in managing patients with full thickness rotator cuff tears that have advanced to massive tears and eventual rotator cuff tear arthropathy. The speakers emphasize the importance of early intervention, suggesting that careful management of these tears can prevent further deterioration and the need for more invasive surgical procedures.

A significant point discussed is the need for a strategic approach to managing full thickness rotator cuff tears. The speakers highlight three main aims for surgery: pain relief, biological healing for improved function and strength, and joint preservation. By implementing effective strategies earlier, such as physical therapy and specific surgical techniques like osteotomies, patients may avoid the progression to rotator cuff tear arthropathy. There’s a mention of innovative approaches being employed in select centers, such as acromial osteotomies aimed at younger patients, indicating a shift towards proactive rather than reactive treatments.

The discussion transitions to the comparative effectiveness of arthroscopic versus open shoulder surgery for rotator cuff issues. Evidence suggests that while the long-term healing outcomes may not differ significantly, arthroscopic surgery offers advantages in terms of reduced swelling, scarring, and a lower risk of postoperative complications due to the flushing effect of fluids used during the procedure. The benefits of this minimally invasive technique are unpacked, making a case for its preferred use in appropriate clinical scenarios.

The lecture also tackles meniscal repairs, addressing the current evidence surrounding their effectiveness and varying outcomes based on the type and timing of the injury, particularly root tears. It is suggested that while repair techniques have improved, understanding the biomechanical impact of meniscal injuries remains crucial. Successful outcomes in repairs seem more likely in acute cases without extrusion, whereas chronic cases require more comprehensive management, often leaning towards non-operative approaches.

Furthermore, the importance of patient education regarding their conditions and treatment options is emphasized throughout the conversation, discussing lifestyle modifications and the psychological benefits of certain physical activities, highlighting the need for a patient-centric approach that balances medical advice with quality of life considerations.

In conclusion, the lecture provides a comprehensive overview of modern practices and considerations involved in the treatment of shoulder injuries, particularly regarding rotator cuff pathology, meniscal repairs, and patient management strategies. The exchange emphasizes the ongoing evolution in surgical techniques and the necessity for tailored approaches based on individual patient presentations, reinforcing the indispensable role of a thorough understanding of these conditions in optimizing patient outcomes.

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Just to start it off, Sumit, we've got a couple of shoulder surgeons in our

practice at Concord, and they do a lot of reverse shoulder arthroplasties.

And they say it's because you do a reverse shoulder when someone has a rotator

cuff tear, but you're saying it's not that simple.

No. And that some patients with rotator cuff tears and rotator cuff arthropathy

should be getting a conventional shoulder.

No. I'm basically saying that the rotator cuff tear arthropathy is the perfect

indication for reverse total shoulder replacement.

But we have to look back at why these patients and this rise in reverses is happening.

And I think the reason why the dramatic rise in reverse total shoulder replacements

is happening is because there was benign neglect of a lot of patients who had

full thickness rotator cuff tears,

then they progressed to having massive tears, and then they progressed to having cuff tear arthropathy.

So then we need to think carefully about how we're managing those patients at

the start because we now know why that disease process is occurring.

So I think careful management of full thickness rotator cuff tears.

And I tell my patients there's several aims for that surgery.

Number one is pain relief.

Number two is biological hearing to improve function and strength.

But the other aim is to preserve their joint.

Because if you actually protect them at that stage, then there's a less likelihood

that they will go down the path of rotator cuff tear arthropathy. That's the first point.

I think that whenever you have a rotator cuff disease and arthritis,

reverse is the right thing to do but there are a lot of patients who have massive tears.

And they have early rotator cuff diarthropathy and

they can still lift up their arm but it hurts to go up but they can hold the

arm up not all of them nerd reverses burning for those patients you can do a

bisonotomy and and they'll they'll improve so are you saying that if we catch

them early and do physio,

we can stop that from progressing?

Or if we catch them early and we osteotomize their calenoid and reorient their

anatomy, we osteotomize their humerus as well, it sounds like,

that we can stop them going down that path?

That's the thing that we're looking at at the moment. So that's not happening right now.

There's one center in Switzerland that's doing it where they're doing acromial

osteotomies to prevent young people from getting osteoarthritis.

And we've looked at that and there's good data on that, but it's not widespread

yet, but it's something that's coming with time.

Okay. We've got a question from the audience.

Arthroscopic keyhole surgery versus open shoulder surgery.

Is there any data on the outcomes or differences between the two?

So arthroscopic surgery, I'm assuming it's for rotator cuff disease.

So in terms of actual data on long-term healing outcomes, arthroscopic versus

mini open surgery predominantly now, there's not that much data that says it's that much better.

But what we do know is that with arthroscopic surgery, in terms of early recovery,

swelling, scarring, risk of infection, it's much lower, specifically with arthroscopy.

Why? Because the solution to dilution is pollution.

Solution to pollution is dilution. Huge amount of fluids is running through

the joint when we're doing arthroscopic surgery.

And therefore, you can imagine there's a great washout that's occurring as you operate.

And so we find that certainly there's a slightly lower infection rate.

And I think in terms of scarring and post-operative capsulitis,

we've also noticed a difference. But in terms of biological healing,

I don't think there's data to say one is better than the other.

Okay. I'd like to ask Michael a question.

So, we've been doing meniscal repairs for a long time.

And do we have, what sort of evidence that we have that,

number one, that the repairs work because, you know, have we gone back and looked

at repairs that were treated with a clot and examined the integrity?

And also that the repairs have the effect on maintaining the biomechanical sort

of integrity that you want to maintain in patients who have,

say, something like a root tear.

So root tear is a different beast and it's got inferior healing outcomes and

also preserving that meniscal function.

So, you know, showed the idea that it just, not just once it progresses, you get that extrusion.

And so, they've found despite the root healing, they haven't been able to improve the extrusion.

And so, there's different repair techniques, particularly from Asia and Korea

and where this is a lot more prevalent and there've been the leaders in it.

But I think that sort of then,

in my hands at least, that if someone's got an acute root tear without extrusion,

then I think my chance of success with the repair are much better and that's

what's been shown with the second look arthroscopies, the second look MRIs.

Whereas in my hands, when someone's got extrusion, they're starting to go having some arthritis.

That's when I'm more looking at their overall alignment and treating the arthritis.

Or in a much older patient, I'm then educating them about their natural history of their disease.

They're starting on the non-operative measures for osteoarthritis and then they'll

come back to me when they're ready for a arthroplasty type surgery.

But meniscal, yeah, the old adages of meniscal repairs don't work.

Peter Myers, for example, from Australia, we've

got really good evidence now that that's just not true in particular they used

to say that the lateral meniscus doesn't heal but and particularly in ACL surgery

you cut it out but that just returns their large cohort studies to show that

that just ruins their return to sport rates and their long-term outcomes after

in particular ACL surgery.

So I was interested to see you say that it was more important to avoid repetitive

movements of the knee to preserve their function rather than high impact loading.

I don't remember saying that specifically, no.

I don't think I said that. No, when I educate patients, I tell them,

best thing I ask them to do is lose weight, which we already heard of today for the knee.

Get an exercise bike because it's got less impact than walking.

And I try to tell them to avoid high impact activities.

But I also have a frank discussion with patients.

Some patients, like myself, get a lot of psychological benefit from running.

So as long as they're not acutely hurting the knee, then it's a great benefit.

Need the endorphins. Yes, exactly. I think we have a question up at the back.

Thank you for the talk to both of you. I have a question about the meniscus preserving or repair.

Does it depend on the type of the tear and the mechanism of the tear that happened?

Or we can preserve all type of meniscus injuries?

It does depend on the tear pattern and the

type but the old adage that you know i've been to talk about

the the radial type tears they're equivalent to a minisectomized knee

and they traditionally were irreparable but

we've got new repair techniques for those type of tears

now uh the parrot beak or the ones where

it's you know a um free nubbin it

has only you know one little base that's not a repairable tear

um and if it's a chronic uh

tear where the tissue pat tissue quality is no longer good uh that's that's

not a tear that's going to heal well with surgery so generally if it's an acute

tear um these these have the chance to be repaired surgically and you need the mri before planned,

Yes, I can't diagnose a meniscus tear.

There's things that will hint to it on the examination, but no,

the MRI is what's going to be my imaging choice to diagnose that.

Thank you. Michael, how long do you wait for the repair of the meniscus?

If you get a young sport injury and our GP will do the MRI, we find that there is a meniscus tear.

And to book to see the orthopedic surgeon maybe sometime takes about two months

and then to prepare for the surgery how long do you wait to repair that tear?

If it's a bucket-handled tear I'll stay back late and get the meniscal surgery

done because they normally have a locked knee and they're quite miserable and in pain.

But generally we want to do the more acutely we can do a repair the more chance

of success So I'll make space for any meniscus tear in a young patient within a month at a minimum.

Regarding the shoulder injury and the rotator cuff injury, most of them,

it happens especially with the older people around 60, 65.

It can happen young, but the older that will give them the option for the operative and non-operative.

What is the chance that in those age group, the older age group? Okay.

So the disease of degenerative rotator cuff disease, that's a very different

disease from an acute full thickness tear in a young patient.

They're a very different disease process. So let's talk about the degenerative

rotator cuff disease, which is your focus there.

Those tend to occur with later in life, and that's because they have a predisposition

based on their scapular anatomy, which increases the forces in the supra and

infraspinatus every time they place their arm in space.

And they keep on tearing and wearing, tearing and wearing, and then you get

a degenerative rotator cuff tear.

In the past, we could not predict function based on the pattern of the tear.

Now, there's a colon classification, which I briefly showed,

which allows us to really predict what a particular pattern of tear will cause

in terms of a functional dysfunction.

So, we used to think elevation is all about the supraspinatus and infraspinatus. That is false.

The most easily treated non-operative management, highest success rate,

75% with physiotherapy and a little bit of steroid injection,

one-off, to calm down the pain, is a supra, isolated supra and infratea. They do fine.

The ones that don't do well are the ones where the upper subscap,

supra and infra are gone, or all of subscapularis are gone. Why?

Because the transverse force couple that holds the humeral head down doesn't work.

These patients have an 85% risk of not being able to lift their arm up.

Doing non-operative management for that is futile. Okay.

We might just, if you want to continue the discussion afterwards,

but I think we need to just move on to the question.