Intro: It's Your Health Radio, a special podcast series presented by Henry Mayo Newhall Hospital. Here's Melanie Cole.

Melanie Cole, MS (Host): It's now possible for certain patients to have total shoulder replacement surgery at Henry Mayo Newhall Hospital's Outpatient Surgery Center and go home the same day. What are the medical and technical advances that have made the same-day total shoulder replacement surgery possible?

Welcome to It's Your Health Radio with Henry Mayo Newhall Hospital. I'm Melanie Cole. And we have a panel for you today with Dr. Theodore Shybut, he's an Orthopedic Sports Medicine physician with the Southern California Orthopedic Institute and he's on the medical staff at Henry Mayo Newhall Hospital; and Matt Crawford, he's a total shoulder replacement surgery patient.

Gentlemen, thank you so much for being with us today. This is very cool. So Dr. Shybut, starting with you. Typically, I'd like you to speak about some of the reasons that a person would need a total shoulder replacement. We think of hip replacements, we think of knee replacements, but shoulder replacement's a whole different ballgame. So, speak about that a little bit.

Dr Theodore Shybut: Thank you for having me on. And I really appreciate Mr. Crawford being willing to do this. Joint replacement is typically a prosthetic or metal and plastic or other materials, but an implant that goes into resurface a joint when the joint is worn out. So, osteoarthritis is the number one reason. The joint sort of lost its normal bearing surface, it's sort of worn down. Commonly, people will say bone-on-bone, painful, stiff and hurts. And so when things get bad enough, then putting a prosthetic joint in, sort of repaving the road with that prosthesis, kind of gives good pain relief and functional outcomes.

And you're right in that hip and knee replacement was sort of developed and maybe more common or more popularized in the past. But the shoulder replacement surgery is certainly growing, is still very common and numbers are increasing. And outpatient shoulder replacement surgery is certainly another growing trend in our field.

Melanie Cole, MS: I find this very exciting, having been in the field for 35 years. I'm way older than both of you. But anyway, historically, how much time when someone had a shoulder replacement, did they spend in the hospital, Dr. Shybut? But because again, we think of knees and hips and they're a little bit more straightforward. But the shoulder, just simply by the fact of how many motions it does and how many muscles connect to make those motions, it's always been a much bigger deal.

Dr Theodore Shybut: Yeah. The soft tissue mechanics around the shoulder are fairly complicated. So, a hip is a really deep socket and has a lot of inherent stability just from the socket part of it, whereas the shoulder socket's really shallow. It's much more like a golf ball on a golf tee in terms of the ball and socket part of the shoulder. So, a lot of people say that an anatomic total shoulder replacement is a soft tissue operation. And even though we're trying to get all the prosthetics implanted to replicate the bony anatomy as best we can, making sure that we handle the soft tissues well and sort of balance them appropriately and around that is really important in terms of the ultimate function.

Going back to your question, when I started as an intern about 20 years ago, shoulder replacements were often in the hospital for a couple of days after surgery, So, a kind of long surgery would happen and then long inpatient stay afterwards. And as things like regional anesthesia and multimodal pain, meaning not just relying on opioids, but kind of a combination of pain medications, including things that are a little bit less sedating have advanced in regional anesthesia, things like nerve blocks to be able to give people less general anesthesia during the surgery and manage their pain afterwards when they wake up, along with just more efficient instrumentation, streamlined surgery, all of those things, and kind of establishing the safety of it, come together to allow people that are reasonably healthy that don't need to be in the hospital to get home faster and faster, and now, same day.

Melanie Cole, MS: Well, that multimodal approach has certainly helped a lot with pain management. So Matt, how did you come to need a total shoulder replacement? Tell us a little bit about your story and how you met Dr. Shybut.

Matt Crawford: Well, it just ended up with pain and I didn't realize how bad it was until after the surgery. But I'm still a paramedic, been a paramedic for over 30 years. And, I think just, it's a hard job on your body, just lifting people and moving them and stuff. And I was active in a lot of extreme sports and stuff, so dislocated my shoulder several times. And I think it just took its toll on it and destroyed it.

Melanie Cole, MS: Now, did you think that you were going to be going home the same day, Matt? Was this talked about in advance? Tell us a little bit about how it all came about.

Matt Crawford: Yeah. We talked about it being an outpatient. The thing was, if there was any complications or whatever, then, you know, it might have to end up a hospital stay, but the goal was to be out the same day.

Melanie Cole, MS: That really is amazing. Now, Dr. Shybut, when we're thinking of total replacements, really what conditions would require that? Now, Matt, as an EMT and lifting people and all of these things, total tears, because we hear about rotator cuff tears and these tears that, "Oh, well, maybe they should be surgically repaired. Maybe they shouldn't. Let's not bother. Do rehab." Why would someone really need this?

Dr Theodore Shybut: So, one is end-stage arthritis. And that can be the arthritis that comes with just having enough birthdays and living a normal life, osteoarthritis. There's something called post-traumatic arthritis, which if you have injuries at a young age that create some damage in the joint or your shoulder dislocates a few times, that can cause trauma to the joint surface. So, it's like a big dose of wear and tear at once that can kind of accelerate things. There are people with inflammatory conditions like rheumatoid arthritis, And all of those can be reasons.

There's also a condition called cuff tear arthropathy. So if you have a really big rotator cuff tear for a long time, the mechanics of the shoulder joints change and it starts to wear unevenly. And then, that a secondary arthritis. And that is also something that we treat with a shoulder replacement, but something called a reverse shoulder replacement, because flipping the ball and socket around adjusts the shoulder mechanics so it's not dependent on the rotator cuff anymore. So if you have kind of a combination of a torn or unhealthy or non-functional rotator cuff and arthritis, severe arthritis together, or just a very, very bad sort of cuff tear that's beyond repair, then reverse shoulder replacement can be an option. Whereas if the rotator cuff is reasonably healthy, generally someone who's just a little bit, maybe more physiologically fit, and we don't tend to do shoulder replacements in young people, but maybe a little bit younger, stronger, healthier rotator cuff, then an anatomic total shoulder is your best option.

Melanie Cole, MS: Shoulders are cool. I really think so. They're so cool. Now, Matt, how did the surgery go? How's your rehab? How do you feel?

Matt Crawford: Well, I'm way in less pain than I was before. Like I said before, I didn't even realize how much pain I was actually in until afterwards. Rehab's going good. It is a long process because, like you said, it's a very complicated area. So, the arm moving everywhere, it takes some time. But it's been going good. And as far as the surgery, I mean, we were in and out of there very quickly. I mean, it wasn't that long, and I slept through most of it. Afterwards, I was on pain medication for like maybe two days and everything went really well.

Melanie Cole, MS: That is amazing. How's your range of motion?

Matt Crawford: It's pretty good. I still can't like put my arm behind my back and get my arm all the way up yet. And I need to build some strength. But besides that, it's going pretty good.

Melanie Cole, MS: That's amazing. If we were on video, you could show us all how much you can move your arm now. And I want to thank you, Matt, for sharing your story. And Dr. Shybut, before we wrap up here, what would you like listeners to know about same-day shoulder replacement? This is an exciting time. This is relatively new. It's not something we've heard a lot about. So, give us a summary, but also tell us where you are doing that and a little bit about the team that's involved to make this happen.

Dr Theodore Shybut: Yeah. That's certainly a big part of it, is having a kind of a good anesthesia team doing a good nerve block and making sure they give just the right amount to keep people like Mr. Crawford asleep during the surgery, but not overly sedating them so they can wake up and go home the same day. Having the OR surgical team, everybody working together to facilitate and work efficiently is helpful.

One of the other things I probably didn't mention, but for surgeries like this, I do a lot of planning in advance of the surgery, so all my shoulder replacements get a CAT scan of the shoulder beforehand, and there's computer software now that basically lets us make a three-dimensional computerized model or digital model of the shoulder so that we can plan our component positions and sizes in advance. So, it's sort of like we've rehearsed the surgery and figured out the size and specifications of the implant that's going in in advance. So, that makes things a lot more streamlined and kind of easy on the day of surgery.

It's certainly not for everybody. I mean, if you're somebody who has a lot of medical comorbidities, you get a really bad heart or just somebody who needs to be monitored in the hospital for a few days afterwards because of an associated medical condition, then trying to sort of force something into an outpatient environment's probably not a good idea. But it's certainly something if you were a candidate for surgery or you talk to your surgeon about it.

The American Academy of Orthopedic Surgeons has a great website called OrthoInfo, I think orthoinfo.aos.org. And that's really good information from expert orthopedic surgeons that's, reviewed for content, but written so that you don't necessarily have to have a medical degree, but meant to be sort of public-facing and it gives a lot of information on procedures like this.

So, we're probably going to continue to see this more and more and just a growing part for people that are appropriate and we get even more experience with outpatient joint replacement surgery. It'll probably become sort of the standard of care and then the people staying overnight will just be if you really have a medical reason or comorbidity or something else going on that's going to keep you.

Melanie Cole, MS: That's fantastic. I love to hear about that. And OrthoInfo is a great website to get information on things like that. And so, thank you both for telling us Matt's story and, Dr. Shybut, for this exciting advancement in shoulder replacement. It is really a cool time in your field.

And Dr. Shybut's website is sportssurgeonssocal.com. And you can also follow him on X, formerly Twitter, @shybutMD. So, you can always go there, learn more. You can also learn more about Henry Mayo Newhall Hospital at henrymayo.com. And of course, always the free health information library at library.henrymayo.com. That concludes this episode of It's Your Health Radio with Henry Mayo Newhall Hospital. Please always remember to subscribe, rate, and review this podcast and all the other Henry Mayo Newhall Hospital podcasts. Until next time, I'm Melanie Cole.