Shoulder Pain Caused by Instability – Dr. Andreas Kiekenbeck: The Goal Is to Resume Physical Activities

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00:00:35: Our shoulder is the most mobile joint in the body.

00:00:39: While it does not have to bear as much weight as the knee or hip, for example where and tear can still occur in the shoulder which may ultimately necessitate a joint replacement.

00:00:49: Today I am very pleased to be discussing this important topic with Dr Andreas Kickenbeck.

00:00:56: He serves as co-owner & lead physician at The Arthos MVZ Orthopedic Practice located in Wiesbaden.

00:01:04: Dr Kickenbeck, could you please explain to us what exactly causes such severe wear and tear in the shoulder joint that a full prosthesis becomes necessary?

00:01:15: In contrast with large joints of lower extremities like hip or knee.

00:01:20: The shoulder is characterized primarily by its remarkably great range of motion.

00:01:25: This means that interplay between the joint surface and complex muscle tendon system is crucial for various degenerative changes.

00:01:34: So, on the one hand we're already talking about normal osteoarthritis as we know it from other joints with loss of roundness and restricted mobility.

00:01:43: We also have patients with underlying rheumatic diseases where their inflammatory changes then truly destroy the joint surface.

00:01:51: However, when we look specifically at the shoulder.

00:01:54: We often see many patients suffering from permanent long-term tendon damage where the complex interplay between the muscular guidance and joint leads to a very significant increase in wear and tear which consequently results into development of osteoarthritis within the joints.

00:02:13: Could you please explain what is actually the single most crucial factor that ultimately leads to decide to recommend a total joint replacement for patients, rather than continuing with some form of conservative treatment?

00:02:27: Pain is clearly primary but for joint replacements loss or function are just as critical.

00:02:32: Patients often complain about constant pain especially with shoulder joints where night pain is excruciating.

00:02:39: Furthermore, and particularly when dealing with arthritic or to put it another way degenerative changes that involve the surface of the joint.

00:02:48: There occurs a massive restriction of movement which severely limits the shoulders.

00:02:52: typically excellent range off mobility too such profound extent That basic self care an essential personal hygiene tasks are sometimes impaired.

00:03:09: There are various types of shoulder prostheses.

00:03:12: Sometimes they only replace the surface of the humeral head, sometimes both the ball and the socket... ...and sometimes a prosthesis is inserted in reverse – that's an inverse prosthesis.

00:03:26: Perhaps we can start with one type.

00:03:29: When do you use a resurfacing prosthesis?

00:03:31: And how does it work?

00:03:33: The term cap-prosthesis….

00:03:36: …is actually a little bit misleading.

00:03:38: In recent years, it has been replaced by what we now call the head prosthesis.

00:03:43: The original cap prosthesis design had several significant biomechanical disadvantages which is why we now refer more frequently to stemless or head prostheses.

00:03:54: These processes offer several advantages particularly for younger patients because they can be implanted in a bone-preserving manner.

00:04:04: This means that in the event of a revision, not as much bone substance needs to be altered in the shaft area.

00:04:11: That is actually one of the key advantages.

00:04:15: Moreover it's important to note that if you choose to utilize significantly smaller grafts... ...you are able to realize substantial improvement regarding overall surgical approach and patient postoperative pain management situation throughout recovery process.

00:04:35: Mobility is, of course being significantly and noticeably improved by the use of this head prosthesis which functions by facilitating the reconstruction of the articular surface of the humeral head.

00:04:51: In what specific cases would you opt for an anatomical total prosthesis where both joint surfaces are actually replaced?

00:05:00: This question is also one where the two actually overlap.

00:05:02: In other words, both a stem prosthesis and head prosthesis can be used as an anatomical total prosthesis.

00:05:10: It has become increasingly clear over the course of these recent years that With a total prosthesis, that is with replacement of the head and corresponding joint partner on shoulder blade.

00:05:24: The glenoid.

00:05:25: when both are replaced satisfaction mobility and also postoperative pain situation are positively improved.

00:05:33: This means if patient has high functional demands which case for almost one hundred percent these days we use an anatomical prosthesis.

00:05:45: whether that is a head short-stem or standard stem prosthesis, then depends more on the patient's bone quality.

00:05:53: Perhaps we could revisit the reverse shoulder prosthesis which swaps natural joint surfaces?

00:05:59: Could you explain specific clinical scenarios where use it and mechanism of how functions?

00:06:07: Actually I believe in Germany at moment about seventy five to eighty percent of shoulder prostheses are reversed.

00:06:16: This is partly because shoulder prosthetics are frequently utilized in elderly patients who have experienced a significant loss of rotator cuff function over the long course their lives.

00:06:29: This brings us back to problem I mentioned at very beginning, The complex interplay between muscle tendon structure and joint surface.

00:06:41: The shoulder joint lacks a form fit, resulting in permanent instability that can only be compensated for by strong musculature.

00:06:50: This means that in our older patients when we no longer have this tendon muscle configuration do we need to create an interlocking fit.

00:06:59: similar avoids the sudden back and forth movement of the shoulder joint allowing the retraining of the deltoid muscles, thus achieving a good everyday function.

00:07:10: for For a significant number of patients, this procedure is truly a genuine blessing because the chronic pain which often leads to severe functional impairment and restricted physical movement in their day-to-day lives has actually resolved and disappears within very short period of time.

00:07:27: And these patients experience significant relief only two or three days following surgical operation.

00:07:33: Some various prostheses that you place need be cemented while others do not require it at all.

00:07:40: Could you please tell me what the specific prerequisites are for this?

00:07:44: As I was pointing out a moment ago when we were deciding between ahead procedures and astem processes, We naturally have to take overall bone quality into our careful consideration.

00:07:55: especially in patients with somewhat compromised bone quality due to known osteoporosis, we face the problem that osteointegration is let's say cautiously suboptimal.

00:08:05: Nevertheless it must be said that cementless implants are predominantly used for the shoulder as In our practice, we generally only choose to cement a stem prosthesis in cases where we encounter significant problematic issues regarding the patient's osteoporotic bone quality or alternatively if following severe accidents.

00:08:34: The inherent bony stability within the proximal that is say near joint section has become compromised.

00:08:40: Can you also perform shoulder replacement surgery minimally invasively using the smallest possible incisions?

00:08:47: The term minimally invasive has a specific connotation when it comes to the shoulder.

00:08:52: We are almost exclusively talking about arthroscopic or endoscopic procedures, of course we cannot do that with endoprosthetics.

00:08:59: What we are able to do, and what we certainly do is utilize a muscle-sparing approach by making the smallest incisions possible in order to avoid causing any additional damage.

00:09:11: This is of paramount importance particularly in the context of anatomical prostheses where we naturally are compelled to gain access beyond the rotator cuff which is the cup shaped covering of the humeral head.

00:09:25: However, there have been significant developments here in recent years.

00:09:28: So the internal rotator, the subscapularis can often be left attached to the front of the humeral head when we implant a stemmed prosthesis or a revision prosthesis.

00:09:38: however We are unable to preserve these tendons In that way.

00:09:43: la

00:09:44: Do you actually perform the surgeries yourself on every single one?

00:09:48: Of the patients who come to your private medical practice?

00:09:51: What's really good and unique about our facility, and orthosis centers in general is that thanks to our specialization and consultation hours patients get to meet their surgeon directly when the decision for surgery is made.

00:10:05: Essentially this means our collaborative decision making process regarding whether a prosthesis is necessary and which specific model to use, is thoroughly discussed and decided during our initial consultation.

00:10:21: You can rest assured that I will perform the surgery

00:10:24: myself.".

00:10:25: So could you explain what happens?

00:10:27: So

00:10:31: in the immediate postoperative phase, which is conducted inpatient comprehensive pain management.

00:10:37: Is first initiated in collaboration with the anesthesiologist it has proven effective to effectively bridge The First twenty four two forty eight hours by utilizing paying catheters and applying local anesthetics In the surgical area Allowing the procedure, the patient is encouraged to begin mobilization quite early.

00:10:58: However that really does depend a bit on just how extensively various tendons had to be reconstructed or surgically reattached.

00:11:06: Initially, passive mobilization is possible here but particularly with the reverse prosthesis.

00:11:12: in older patients active assistance and exercises are provided directly on the first and second post-operative day to reduce the hematoma as quickly as possible.

00:11:27: Typically, rehabilitation follows often involving an outpatient program for the shoulder that includes intensified lymphatic drainage and physical therapy.

00:11:38: A distinction must be made here as well.

00:11:41: with a reverse shoulder prosthesis The patient needs to get used And that is of course a time factor, even though pain improves very quickly especially with an inverse prosthesis due to the altered biomechanics.

00:11:58: We lengthen the arms slightly meaning we destilize and medialized the pivot point of the humeral head.

00:12:05: In this particular instance, the patient has been dealing with this for a period of ten to sixteen weeks and we are well aware that the improvement in muscle strength really takes place over a span of six-to twelve months.

00:12:21: What is your experience like generally speaking?

00:12:24: How long does it take for shoulder prosthesis to heal

00:12:27: properly?".

00:12:31: So within one to two weeks we are actually in a satisfactory range.

00:12:35: We know that head prostheses require slightly more careful follow-up treatment because depending on the type, the anchoring also takes six to eight weeks.

00:12:46: The entire process is generally limited by the soft tissue reconstruction, specifically the venous sutures which often require four to six weeks before they can handle active loading again.

00:12:58: It usually takes six to eight weeks for a patient to achieve truly satisfactory healing and significant progress...

00:13:05: And after undergoing shoulder replacement will all of your arm movements be possible once?

00:13:11: or are there any specific limitations, for example regarding the amount of strength that you will have in?

00:13:27: While this specific goal is often not achieved to the full one hundred percent, when we compare it with a patient's initial situation there are truly significant and very noticeable improvements.

00:13:37: In most cases patients can reasonably expect to regain normal healthy joint function.

00:13:42: however in an inverse prosthesis.

00:13:45: overall range of mobility is inherently limited by its design due to built-in mechanical stop.

00:13:51: However, it is the gain in range of motion here that is absolutely crucial for the patient.

00:13:56: Regarding strength there's a very interesting recent study where the question naturally arises can you really do all sports again with a prosthesis?

00:14:03: Of course There are many patients who would like to resume non-contact sports afterwards.

00:14:10: That includes jogging, dancing gymnastics or using a home trainer.

00:14:14: Cycling is also really popular.

00:14:16: Golfing is possible with a prosthesis but obviously no contact sports.

00:14:22: that limitation exists.

00:14:24: Regarding the strength in our older patients, a reduction of strength is observed here With anatomical prostheses.

00:14:32: we expect that strength will be restored in long term.

00:14:35: You were mentioning younger patient earlier.

00:14:38: Could you tell me how long a shoulder replacement usually lasts?

00:14:42: Much like with other types of prosthetic devices, this naturally depends on the level of physical stress and frequency of movement exerted by patients themselves.

00:14:50: For younger patients we can still expect very favourable results lasting for over fifteen years... ...with survival rates consistently exceeding ninety percent.

00:15:03: These are the head processes, which a more recent development.

00:15:08: Naturally not all of them have been fully studied yet but the current trend is that these processes also allow for excellent long-term durability and as I mentioned because they use bone sparing procedures.

00:15:21: it can be revised quite easily then will still allow for perfectly normal functional anatomical joint configuration.

00:15:31: So, to follow up on the point you just made.

00:15:34: Much like a knee or hip replacement A shoulder replacement can also be replaced second time if any significant complications arise.

00:15:43: Yes!

00:15:43: Revision surgeries for shoulder prostheses are possible.

00:15:46: They're quite feasible and generally put much less strain on patient than for example a knee-or-hip replacement revision.

00:15:54: The patient is mobilized quickly and does not need to use crutches.

00:15:58: Yes, post-operatively it's common for a sling to prevent uncontrolled movements during the night.

00:16:03: however revision options are available.

00:16:06: this naturally easier with head prostheses than with stem prosthesis or in case of periprostatic fracture but here we can really put those fears into perspective.

00:16:18: Revision options for shoulder prosthetics.

00:16:21: Thank you very much for your explanations, Dr.

00:16:24: Kiegenbeck!

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