On the Mayo Clinic Q&A podcast, Dr. Joaquin Sanchez-Sotelo, a Mayo Clinic orthopedic surgeon, discusses advances in shoulder replacement surgery, including custom-fitted implants.
Show Notes
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Mayo Clinic Q&A
Narrator: Coming up on Mayo
Clinic Q&A, a look at custom-fit
shoulder replacement.
Dr. Joaquin Sanchez-Sotelo: Another
is this fascinating technology
where you can tell a computer
program where is it that you
want your implant planned. For
orthopedics, it is very
important that the implant lands
exactly in that location. And
then with 3D technology, you can
create a metallic envelope that
will fill in the defects that
are present in the bone.
Narrator: Shoulder replacement
is one of the most successful
orthopedic surgical procedures
today. And Mayo Clinic surgeons
are using cutting-edge software
to create a shoulder joint that
precisely fits the patient.
Dr. Joaquin Sanchez-Sotelo: And
then as a surgeon, you plan the
surgery virtually and decide for
that patient, where is it that
you want the component to land.
The benefits are, as I said, you
are guaranteeing the patient
that the implant is goiong to
fit his or her shoulder, number
one. Number two, it decreases
the surgical time tremendously.
Dr. Halena Gazelka: Welcome,
everyone to Mayo Clinic Q&A. I'm
your host Dr. Halena Gazelka.
Shoulder replacement surgery is
done to relieve pain and other
symptoms that result from damage
to the shoulder joint.
Traditionally, shoulder
replacement removes damaged
areas of bone and replaces them
with standard parts made of
metal and plastic. Thanks to new
technology, there's another
option. Using CT scans and 3D
modeling, patients can now
receive joint replacements that
are custom fit to their anatomy.
With me today to discuss this is
Mayo Clinic orthopedic surgeon,
Dr. Joaquin Sanchez-Sotelo.
Thanks for being here today,
Joaquin.
Dr. Joaquin Sanchez-Sotelo: Of
course, Halena. Thank you for
having me.
Dr. Halena Gazelka: I think this
is just fascinating. And I can't
wait to hear the benefits of
this for patients, which I'm
sure are numerous. But first,
can you tell us how common is it
to have to replace someone's
shoulder joint? And who do you
do it for?
Dr. Joaquin Sanchez-Sotelo: That
is a great question, Halena. So
the rate of usage of shoulder
replacement in the United States
has increased dramatically. And
I think there are two reasons.
One, is that implants are
better. And also that patients
now are more active with their
upper extremities later in life.
So they need the procedure
because they want to have a life
where they can enjoy activities
pain free. So currently, there
are more than 100,000
arthroplasties of the shoulder
done in the United States every
year. And the projection is that
by 2025, there will be 250,000
replacements every year. So
very, very common. You were
asking what are the most common
reasons. So to be honest, the
most common are two of them. One
is what we call plain
osteoarthritis, where in a ball
and socket joint like the
shoulder, the cartilage of the
joint disintegrates. And that
leaves the raw bone exposed, and
that's painful. So that's one
very common indication. A
second, is actually patients
that have a long-standing tear
of their rotator cuff. And then
the joint degenerates secondary
we call that cuff tear
arthropathy. Of course, there
are other reasons, maybe a
fracture sometimes or congenital
disease, but the two most common
will be primary osteoarthritis
and cuff tear arthropathy.
Dr. Halena Gazelka: So during
the intro, I mentioned that
traditional joint replacement
has involved taking something
that is metal and plastic
essentially, made in a factory,
not specific to someone but made
in sizes, and then you replace
the shoulder joint. So what are
the benefits and disadvantages
of traditional methods of
replacing shoulders?
Dr. Joaquin Sanchez-Sotelo: Yeah,
so one issue that we have in the
shoulder in particular is that,
as I said, this is a ball and
socket joint, the socket, that
is called the glenoid, is
actually very small in humans.
So for people that can see the
image if you're not just
listening, I'm showing a model
of the scapula, which is a very
interesting bone. And the socket
of the shoulder is at the corner
of the scapula. And it's already
a small bone to begin with, It
is tiny. And not uncommonly,
this bone is actually deformed
when someone needs a
replacement. So I have another
model that you may compare to
the one I showed and not sure if
you can see it very well in the
screen, but this particular
scapula, glenoid, has been
missing on the back as opposed
to a normal glenoid. So
traditionally, when we had to
fit a component in the socket,
the only way to do it, is as you
said, take an off-the-shelf
implant, and then remove more
bone to adapt it. And the
downside of that is that you're
already working on a small bone
that already has bone loss, and
then you remove more bone to
place the implant. So then the
implant is now a very deep
portion of the joint, which
mechanical is not ideal. And if
that were to fail, you as a
surgeon have already removed all
the bone. So now there is this
fascinating technology where you
can tell a computer program
where is it that you want your
implant to land. For
orthopedics, it is very
important that the implant lands
exactly in that location. And
then we 3D technology you can
create a metallic envelope it is
called, that will fill in the
defects that are present in the
bone. So, for example, this is
one such component, this is
called the baseplate component
of a reversal prosthesis. And
the part that we know want to
land somewhere is the metallic,
more shiny part, right?
Traditionally, these have a flat
back, so you basically rim the
bone and place them. But now
what you can do is you can place
the components virtually in a
computer program, whatever you
think it has to be, hit a
button, and then the computer
will calculate this form of
metal. And it's interesting
because human bone grows very
well into titanium. And then the
company will send you a model.
So, this will be the scapula
adaptation that you can confirm
that is going to fit perfectly
in this patient. So you can see
how you will have perfect fit.
And they come up with a guide
you can use in the operating
room for the component. That's
exactly where, where you want it
to land. And I must disclose
that I help Stryker Corporation
with implant design forMayo
Clinic, even though I didn't
help with this particular
design, but that's important for
the listeners to know about our
potential conflict of interest.
Dr. Halena Gazelka: That's
absolutely fascinating. And I
could see there must be
significant advantages, how long
has this been available?
Dr. Joaquin Sanchez-Sotelo: So
it was released to the market,
actually this year. So it's
completely brand new technology
that I think is going to
transform our practice. But the
benefits are, as I said, You are
guaranteeing the patient that
the implant is gonna fit his or
her shoulder, number one. Number
two, it decreases surgical time
tremendously. Because in the
past, you had to get exposure
and then prepare the bone until
it fits one of the parts that
are on the shelves. Now you know
that the part you are getting is
gonna fit that patient's
anatomy. So you basically open
the box, get that plugged in and
place it, we're basically done.
So surgery time is less. And
it's also very cost-effective
for hospitals, because then you
have only one component per
patient, as opposed to having a
lot of them on the shelf.
Dr. Halena Gazelka: Well, that's
really interesting. So, the
surgical time is less, but I
would imagine there must be some
prep time ahead, and what's the
process that you go through to
develop a custom joint for a
patient?
Dr. Joaquin Sanchez-Sotelo: So
for this particular system,
typically the surgeon will plan
the case. So you get the CT scan
of the patient, it comes from
something called DICOM files
that you can upload in the
software. And then as a surgeon,
you plan the surgery virtually,
and decide for that patient,
where is it that you want the
component to land, and that
takes about 5 to 10 minutes
approximately, Then you hit the
button that gets the metal
envelope, and the component is
shipped to the hospital within
typically one month. You have to
plan the surgery at least a
month in advance. But the prep
time on the side of the surgeon
is actually maybe 10 to 15
minutes, so it's not that much.
And then when the day of surgery
occurs, you basically get
exposure, you have to drill the
bone to get this back on the
post. But everything else all
the irregular bone that the
patient may have, is perfectly
matched to the irregular surface
of titanium that the company
made for that patient.
Dr. Halena Gazelka: Wow. So I
think some of the benefits are
obvious. And you mentioned them.
Are there any disadvantages to
this type of joint replacement?
Dr. Joaquin Sanchez-Sotelo: Yeah,
so the two main ones will be
that if for whatever reason, the
implant gets damaged or
contaminated in the operating
room, you can't use it, right?
Because they only ship one. So
as a surgeon, you have to be
careful because if for whatever
reason it gets damaged or maybe
contaminated, including
infection, you have to go back
to the regular replacement,
which is not a big deal. And
then the second, is that as you
probably know, in health care,
every single adjustment comes
with a premium financially. So
this component is slightly more
expensive than the official one,
but not by much.
Dr. Halena Gazelka: So I imagine
you still, at times, do a
traditional joint replacement.
And how do you decide if someone
is a candidate to have a custom
joint replacement versus using a
traditional method?
Dr. Joaquin Sanchez-Sotelo: Yeah,
the main limitation of the
custom made prosthesis is that
the thickness of the envelope
that was approved by the Food
and Drug Administration is
limited. Because as you know, in
North America, the FDA is very
careful about only launching
implants are for sure going to
work. So they didn't have enough
testing to be able to create an
envelope that will be very, very
large. I'm talking about 2,3,4
centimeters. So for people with
really severe deformity, this
implant cannot be built. So
there are patients that come
with so much bone missing that
the only way to reconstruct that
shoulder is to use bone graft,
typically from the waistline
like iliac crest or other
locations. And then the second
limitation can be cost and time.
So, if someone really wants to
have the operation the day after
he or she seen in consultation,
of course, you don't have that
month of leeway. And you need
the CT scan, which is radiation.
But today, I will argue that the
majority of shoulder
arthroplasties, in the United
States are done, always, with a
CT scan is part of our routine
right now. So that doesn't
change much the workflow fo the
patient or the surgeon.
Dr. Halena Gazelka: Well, that's
just fascinating. I'm curious
how widespread this is, Joaquin.
Is it available in most
orthopedic practices or only at
large medical centers?
Dr. Joaquin Sanchez-Sotelo: So
this is just starting. And I
think, as with everything else,
we just have to be confident
that new technology really helps
our patients. But my prediction
is that this is going to
continue to expand. Right now
there is only one company making
these for the primary
applications. There are other
companies making it for more
custom applications, for very
complex deformities. I think we
will expand. But one of the
beauties of the podcast you run
is that it brings to the
patients or prospective patients
an idea of how quickly
technology is moving and what
new things are coming out that
have truly potential to improve
patient outcomes.
Dr. Halena Gazelka: Joaquin, I'm
really curious, is custom joint
replacement, something that's
also being developed for other
joints or the shoulders unique
in some way that you need this?
Dr. Joaquin Sanchez-Sotelo: No,
in fact, this initially started
in knee replacement, actually.
There was one company that
basically was created to develop
custom made implants for knee
arthroplasty. And that, to some
extent, has not been used very
commonly in the knee because in
knee replacement, there is a lot
of use of robotic surgery, which
is not present in the shoulder.
But also, the bones in the knees
are bigger, so you have more
freedom as a surgeon to maybe
remove some more here and there
and still fit the implant. The
challenge with the shoulder is
that the socket of the shoulder
is so small, that is really
beneficial to not remove any
bone, period. So if you can
basically build up the missing
bone with metallic augment, it
is much more superior in the
shoulder than removing bone so
you can fit an off-the-shelf
implant.
Dr. Halena Gazelka: We talked
about how the surgical time is
decreased by using a custom
implant. And I'm also wondering
about the recovery. Because I'm
thinking about some of my older
patients in the pain clinic who
really are extremely limited.
They can't use a walker because
they have shoulder issues and
mobility is a real issue. How is
the recovery for this?
Dr. Joaquin Sanchez-Sotelo: Yeah,
the recovery in general, for
shoulder replacement — this has
nothing to do with patient
matched implants — I'm talking
about in general, has improved
tremendously. And to the credit
of your specialty, it is mostly
because of anesthesiologists and
pain doctors. So, when I was a
fellow, shoulder surgery was
perceived to be one of the most
painful experiences that one can
go through in orthopedics. And
now, thanks to the advances that
you and people in your field
have done with peripheral nerve
blocks, it's incredible to me
that most patients tell me, you
know, I had no pain in surgery.
As you know, we offer patients a
block before surgery. And you
know this better than I do. But
that concept of preemptive
analgesia really works, meaning
that when the block has been
done, as you know better than I
do, the brain really doesn't
know that there was an operation
done because the feeling was
blocked. So the thymus doesn't
get sensitized, I don't think.
And patients have a very
pain-free experience. And the
other thing that comes as a
question in my clinic all the
time is people are older
75,80,82, 85 that already
disabled. Provided they are
reasonably healthy, we have
three studies from our practice
that showed that the recovery
and complication rate is
identical to younger patients.
So we no longer consider
advanced age a contraindication
for surgery, provided the
patient is healthy enough. And
there are some people that,
without replacement of the
shoulder, they will have to move
in with a family member or go to
a nursing home. Whereas if they
have the shoulder replacement,
they can function, they can
actually leave a home and enjoy
a more independent life.
Dr. Halena Gazelka: What
wonderful work you are doing.
Thank you, Joaquin. Any last
words you'd like to share with
our audience today?
Dr. Joaquin Sanchez-Sotelo: Well,
I just want to highlight how
beneficial this operation can be
for patients that really need
it. And also to stay tuned
because technology is advancing
so fast. You know, we have now
electric cars, and smartphones,
and I Watches this and things
that have really changed in the
way we handle technology and
that's transpiring into medicine
or orthopedic surgery. So I'm
just excited to see how many
more things are coming out. That
can really, really change the
outcome of the operation, make
it faster, make it easier, and
lead to a much better outcome.
Dr. Halena Gazelka: It is so
exciting to learn all of the new
developments in medicine going
on. Thank you for being here to
share them today, Joaquin.
Dr. Joaquin Sanchez-Sotelo: Thank
you for having me. It's always
wonderful to talk to you.
Dr. Halena Gazelka: Our thanks
to Mayo Clinic orthopedic
surgeon, Dr. Joaquin
Sanchez-Sotelo, for being here
today to talk to us about custom
shoulder joint replacement. I
hope that you'll learned,
something. I know that I did. We
wish each of you a wonderful
day.
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