A day in theatre
A productive day in the operating theatre with Dr James McLean, discussing shoulder replacement surgery and sharing our respective experiences.
Comparing approaches with a surgeon who does the same operations differently is one of the more useful forms of continuing education, because the differences are where the genuine uncertainty lies. Thank you for visiting.
What shoulder replacement involves
In a shoulder replacement the worn surfaces of the joint are removed and replaced with artificial components. In an anatomic total shoulder replacement the ball at the top of the humerus is replaced with a metal ball and the socket is resurfaced with a plastic liner, reproducing the normal arrangement of the joint. It depends on the rotator cuff tendons still working, because those tendons hold the ball centred in the socket while the arm is raised. In a reverse total shoulder replacement the arrangement is inverted: a socket is fixed to the top of the humerus and a ball is fixed to the shoulder blade, so the deltoid muscle can lift the arm when the rotator cuff is no longer able to. Which of the two is appropriate depends on the state of the cuff, the shape and bone stock of the socket, the diagnosis and the patient's age and activity. Individual results vary.
Why surgeons visit one another's theatres
Reading a surgeon's published series tells you what they did and what happened. Standing in their theatre tells you how they did it, which is a different body of information: how the patient is positioned, which instruments are laid out and in what order, where the incision is placed, how the soft tissue is handled, and what the surgeon does when the anatomy is not as the scans suggested. Much of that is never written down because it is assumed rather than described. The conversation during a case is where the reasoning behind each choice gets stated out loud, including the choices the surgeon has changed over the years and why.
What gets compared
In shoulder replacement the points of difference between experienced surgeons are fairly consistent: the surgical approach and how much of the subscapularis tendon is taken down and repaired, the choice between anatomic and reverse replacement in borderline cases, how bone loss or wear in the socket is managed, how far the implant is positioned to favour range of movement against stability, and how rehabilitation is directed afterwards. These are the areas where the evidence does not yet decide the matter, which is exactly why they are worth discussing in person. Individual results vary.