Wave, March / April 2013
Marvin Matters shifts nervously on the gurney as he contemplates the events that are about to unfold over the next two hours.
The 69-year-old retired farmer from Ste. Rose du Lac suffers from osteoarthritis in his shoulder, a condition so painful that even shuffling a deck of cards has become excruciating. "I can move it," he says. "But I get a sharp pain in there. It's keeping me awake at night."
The situation has deteriorated to the point that the cartilage in Matters' shoulder socket has entirely worn away. Without this buffer, the upper arm rubs boneon- bone with the shoulder's socket, causing pain and limiting motion. "Lately, it's been bad. I can't do much," he explains. "I can't even play pool anymore with my buddies at the seniors centre in Ste. Rose."
And so now, Matters, a man most comfortable in jeans, a shirt and his camouflage hunting cap, finds himself here on this January morning in the pre-op area of the Pan Am Clinic, dressed in a light blue gown and cap, preparing for what he hopes will solve his problem: total shoulder replacement surgery.
As it turns out, Matters will be one of two patients to undergo total shoulder replacement surgery at the clinic during the month of January. In both cases, the patients will benefit from a new approach to performing these types of operations in the Winnipeg Health Region, one that is designed to reduce wait times and increase operational efficiencies.
Much of the credit for this innovative approach goes to Dr. Jamie Dubberley, one of five orthopedic shoulder surgeons in Manitoba who perform these types of procedures, and the man who will be operating on Matters this morning.
As Dubberley explains, total shoulder replacement surgeries are usually performed in hospital. The operation itself involves a large incision over the shoulder, detaching the tendons, dislocating the shoulder, then sawing off the humeral head and replacing it and the socket with stainless steel and polyethylene parts.
"Traditionally, this is considered a major procedure, and it has been done at the hospital because it was felt to be more painful and the people who get them are sometimes advanced in age and have other medical issues," says Dubberley.
The problem with that, though, is that it can take up to 12 months from the time the surgery is booked to when the surgery is performed. Moreover, a patient admitted to hospital for shoulder replacement surgery usually stays for another two days.
So, a couple of years ago, Dubberley started to wonder about what could be done to reduce wait times and get patients home sooner.
As a member of the Pan Am Clinic's surgical team, he was already doing minor shoulder surgeries - such as repairing torn ligaments - as part of the clinic's outpatient surgical program, which allows patients to go home the same day the procedure is completed.
His experience got Dubberley thinking: Could total shoulder replacement procedures be done on an out-patient basis?
Dubberley researched the concept and discovered a successful shoulder surgery out-patient program in Ontario. He then checked his own files to see how patients had fared following their hospital operations in 2010.
"To my surprise, for that year, no patient stayed in hospital more than two days, there were no referrals to any other medical services, and no other treatments, such as a blood transfusion, were required. I knew there were still some patients who, due to medical conditions or age, who would still need to be done in hospital, but there were likely a number of patients who would do well with out-patient surgery."
Dubberley met with Dr. Luis Oppenheimer, Provincial Director of Patient Access, and Dr. Peter MacDonald, Head of Orthopedics at the Pan Am Clinic and Leader of Orthopedics for the Winnipeg Health Region, to discuss his idea. With their support, he put forward a proposal to the Region to a run a trial program at the Pan Am Clinic with the goal of reducing shoulder replacement surgery wait times by as much as 50 per cent.
"We decided that we would offer this procedure to younger, healthy, shoulder arthritis patients who had good home support," Dubberley says.
But that was just the start of the process. To pull it off, they needed to have anaesthesiologists on board. After consulting with anaesthesiologists Drs. Ken Ringaert and Ryan Amadeo, who both work at the Pan Am Clinic, they determined it would be possible to safely provide a long-lasting nerve block to a patient, which would allow him or her to go home the same day.
Yet even with the green light, a lot of work needed to be done before the first procedure could take place. Nurses required training to help screen the patients to ensure they were fit for this kind of surgery. They consulted with physiotherapists to develop exercises for out-patients to strengthen their shoulders in the weeks following surgery.
Even a representative from the manufacturer of the stainless steel and polyethylene replacement parts for the shoulder had to be brought on board to train nurses at Pan Am - who were enthusiastic about working on the procedure, but hadn't done this type of surgery for awhile.
Lastly, the Region would have to find about 40 patients who would be a good fit for the procedure at the clinic. "Dr. MacDonald and I identified the patients we thought were appropriate," Dubberley says. "Then their families had to be on board, as these patients would need someone to monitor them overnight and do dressing changes, etc."
The first total shoulder replacement operation was successfully performed at the clinic in September 2011. Matters would be No. 23.
It is now 8 a.m. Matters has been prepped by nurses Rhonda Fortier and Sylvia Starmer, and is ready to be rolled into Operating Room 1.
Once inside, anaesthesiologist Dr. Fahd Al Gurashi and Regina Kostetsky, an anaesthesia clinical assistant, get to work. They use ultrasound to find the major nerve running to Matters' shoulder and inject it with a freezing agent that will block feeling in his shoulder for the next 24 to 48 hours.
Meanwhile, the operating room nurses prepare the tools of the trade, carefully laying them out next to the operating table. It's an odd combination. The typical surgical tools, like clamps and scalpels, are there. But so, too, are the shoulder replacement parts, which look like they belong in an auto mechanic shop. And then there is the special cordless drill, a number of bits, screws and other components.
"Marvin, I'm just going to ask you a few questions to make sure we're all on the same page," says Fortier, the circulating nurse. "Your name is Marvin Matters, correct? We're working on your right shoulder? We're doing a total shoulder arthroplasty? We're fixing the whole darn thing. It's a replacement, OK?"
Matters answers yes to all the questions.
Shortly after, Dubberley enters the operating room and looks at Matters' X-ray on a computer.
"He has advanced arthritis," he says, pointing at the screen. "We're going to take a saw and cut off the head (of the bone) here. Then we put a new plastic socket in and then a metal ball that we screw into the head of the bone. It's pretty standard. There's nothing really unusual about it."
Meanwhile, Al Gurashi and Kostetsky continue to work with Matters. They have him hooked up to a machine that monitors his breathing, heart rate, blood oxygen levels and blood pressure.
His vitals will be watched carefully, second-to-second, minute-to-minute, for the next two hours.
"Now it's time to go to sleep," says Kostetsky. "Ready?"
Al Gurashi places an anaesthesia mask over Matters' face.
"Nice deep breaths, Marvin," he says.
"Sweet dreams," Kostetsky adds. "We will see you later."
By 8:20 a.m., Matters is sleeping peacefully.
The next 20 minutes is spent prepping Matters for the operation. Every part of his body is covered up, save for the area of his shoulder - about 20 centimetres in diameter - where the procedure will take place.
His head is put into a brace so it doesn't move during surgery, and his right hand is wrapped in light blue foam padding and placed in the Trimano, a stainless steel device that holds Matters' arm in precise positions to facilitate the surgeon's access to the shoulder area.
At about 8:45 a.m., everything is ready. Dubberley presses "play" on his iPod. Crowded House's Better Be Home Soon can be heard playing in the background as he makes the first incision, about 20 centimetres (eight inches) along the front of Matters' right shoulder.
Dubberley carefully spreads apart the tissue and cuts the tendons that connect the muscles to the bones and cauterizes the blood vessels to stop the bleeding. Along with the help of Fortier and Dave Vancura, a fourth-year medical student from the University of Manitoba, Dubberley dislocates Matters' shoulder, turning it outwards about 120 degrees. This provides good access to the humeral head - the top of Matters' arm bone - that will be removed and replaced with a stainless steel half-ball.
Dubberley then uses a surgical saw to remove the top of the bone, carefully measuring the cut beforehand so the replacement part is an exact fit.
Next, Dubberley drills holes into the top of the humerus and uses screws to fasten a stainless steel trunnion to the bone that will keep the new ball joint in place.
It's 9:20 a.m. Fortier wipes beads of sweat from Dubberley's forehead as he now moves onto the socket located on the shoulder blade. The socket is comprised of a glenoid fossa (the socket cavity) and the glenoid labrum (the cartilage that fits around the rim of the cavity). Much of Matters' glenoid labrum has worn away, but the remnants must still be cleared out.
Once that is done, Dubberley drills holes into the socket bone structure of the shoulder blade just above Matters' armpit. Next, he prepares a cement glue that will be used to hold the glenoid replacement in place.
"This is the most intense part of the operation," Dubberley says. After the glue is applied, they have 10 minutes to place the polyethylene glenoid into Matters' socket properly.
"You want to do it right because nobody likes taking cement out after it dries," he says.
Fortier unwraps the glenoid replacement, which is double-packaged to assure it's completely sterile, and hands it to Dubberley, who places it into the socket.
With the new glenoid successfully in place, Dubberley turns his attention back to the humeral head replacement.
Fortier unwraps both the stainless steel ball, along with the trunnion and cage screw that will hold the ball joint in place.
By 10 a.m., he is ready to insert the cage screw - to which the new humeral head will attach - into the trunnion. Dubberley then twists the new head onto the cage screw until it's firmly attached.
With all Matters' new parts now in place, Dubberley starts closing up the incision. He re-attaches the tendons, sewing them together as they once were, and then stitches up the tissues and skin until all that can be seen is a perfectly neat seam in Matters' shoulder, which had only a few minutes before been literally exposed to the bone.
By 10:20 a.m., Matters' incision is covered with a bandage, and the team begins unwrapping him, pulling away the covers, and then removing his arm from the foam protection and the Trimano. Last, they free his head from the brace, and then transfer him from the operating room table to a gurney.
"Martin, open your eyes," Al Gurashi, the anesthesiologist. He repeats this four more times until Matters awakes.
As he is wheeled out of the operating room at 10:36 a.m., Matters asks a critical question: "Did everything go okay?"
"Everything went fine, Marvin," Dubberley says.
Matters spends the next two hours recovering in post-op. With pain under control and no signs of complications, he is told he can go home. His wife, Barb, picks him up and they stay overnight with friends in St. Vital. The next morning, Matters wakes up in pain. Although not as much as he had felt in the past from his arthritis, it's enough that he needs a prescription painkiller to dull the discomfort for a three-hour ride home.
While the operation is over, Matters' long road to recovery is only beginning.
"The pain is usually better quite quickly," Dubberley says. "They usually notice a big difference within a couple of weeks, and then the range of motion comes back, and the shoulder slowly gets stronger over the next few months."
Many patients go to physiotherapy to help them get back to as close to normal as possible within a year.
"Usually, they know how good it's going to be around six months," he says.
Although many recipients of a new shoulder can again do many activities pain-free, they also want the new joint to last, so they always have to remember not to over-exert themselves. If they play tennis, for example, they have to ease their way back into the sport.
"You still might be limited in some things, but overall, you don't have to be concerned about throwing to your grandkids or something like that."
In the days and weeks after the procedure, the surgeons follow up with the patients to ensure they're healing as they should be. Their overall progress will be monitored for the next few years.
Like all total shoulder replacement patients, Matters' first follow-up is at the two-week mark. And so, on February 13, Matters - with his wife, Barb, and his daughter, Bev Keith, in tow - arrives for his appointment at the Pan Am Clinic for a check up.
"So how are you doing, Marvin?" asks a smiling Dubberley.
Matters replies: "I can't believe I've hardly had any pain. I mean I haven't been playing hockey or anything, but it's been really good."
Barb chimes in: "But he wants to play pool."
Dubberley removes the bandage from the surgery and looks at the incision. He examines the noticeable scar and remaining stitches, but he sees no telltale redness or swelling from infection.
"It's healed perfectly," he says.
"Like I said, I'm a good healer," Matters replies. "You did a fantastic job."
Dubberley then asks Matters to move his arm gently in different directions. Marvin does so gingerly and feels some pain. This is normal, Dubberley assures him. More range of motion without pain will return soon enough.
"You won't want to shoot a rifle for quite a while," he says to Matters. "But you're doing very well."
With everything looking good on the surface, Dubberley sends Matters for an X-ray to ensure there's no dislocation or anything untoward going on under the skin. Fifteen minutes later, Matters returns from X-ray and Dubberley shows the Matters family the results. They marvel over the very discernible, large bolt in his shoulder - the stainless steel ball joint permanently screwed into his upper arm bone.
Both Barb and Bev express amazement at how quickly and noticeably improved his shoulder has been, even a couple of days after the procedure.
"I'm shocked because when I talked to him a week after surgery, he said it was better, and I was like, 'Oh, wow that is fast!'" his daughter says.
Dubberley points to the new shoulder joint. He then circles with his finger on the X-ray the light outline of the plastic glenoid, which now replaces the cartilage in the shoulder joint.
"That was bone-on-bone two weeks ago," he says. "That's why there was so much pain."
Matters repeats that he can't believe how good it feels.
"Yeah, that's why we can do it this way," Dubberley says. "Otherwise, the wait is over a year to get into surgery at a hospital."
Wrapping up, Dubberley says because Matters has healed so well, he can skip the six-week follow-up and come back in three months.
But Barb has one more question before they leave for home.
"He's really been wondering if he could go play pool at the seniors centre. Is it too soon?" she asks.
"Pool might be OK," Dubberley says, adding it's moving the arm to the side and up away from the body that he's not to do for another month.
"But moving his arm straight forward in a pool cue motion should be OK," he says. "So go ahead and enjoy shooting some pool with your buddies again."
Joel Schlesinger is a Winnipeg writer.
The out-patient total shoulder replacement surgery program at the Pan Am Clinic is a prime example of how the Winnipeg Health Region is working to
provide the right care to the right patients at the right time.
Historically, these operations have been performed in hospital. But competing demands for operating room time can mean longer wait times for patients who need the operation. In addition, patients who have the procedure done in hospital usually spend a day or two in hospital recovering from surgery.
Under the Pan Am Clinic program, patients deemed to be suitable candidates are booked for surgery at the clinic, thereby avoiding the wait for hospital operating rooms. In addition, patients are released from care following surgery rather than staying in hospital.
By the numbers
- 100 Manitobans require total shoulder replacement surgery every year.
- 80 Manitobans received total shoulder replacement surgery in 2011.
- 100 Manitobans received total replacement surgery in 2012.
- It takes approximately 12 months to book a hospital operating room for total shoulder replacement surgery.
- It takes approximately 3 to 6 months to book total shoulder replacement surgery at the Pan Am Clinic from time of consult.
Anatomy of a shoulder replacement operation
The shoulder is a ball-and-socket joint. As shown in image A, it is made up of three bones: the humerus (arm bone) scapula (shoulder blade) and clavicle (collar bone). At the top of the arm bone is a ball, called the humerus head. It fits into a socket, called the glenoid fossa, housed in the shoulder blade. The glenoid fossa is surrounded by a cartilage known as the glenoid labrum, which essentially prevents the arm bone from coming out of the socket.
Problems can arise with the emergence of osteoarthritis in the shoulder. Essentially, this causes the cartilage around the socket to wear down. This leads to friction with the ball of the arm bone, which results in pain and limited motion of the arm.
Total shoulder replacement surgery essentially involves replacing the ball joint and socket with artificial components. Here is how the procedure is performed:
1. An incision, about 20 centimetres (eight inches) in length is made on the patient's shoulder.
2. The tissue is spread apart, tendons and muscles that hold the ball and socket in place are cut, and blood vessels are cauterized.
3. The shoulder is dislocated from the socket, and the arm is turned outwards, providing access to the humeral head - the top of the arm bone.
4. A surgical saw is used to remove the top of the bone, as shown in image B. A drill is used to make holes in the arm bone. Using special screws, the surgeon attaches a stainless steel trunnion to the arm bone. This trunnion will eventually hold the metal ball that will replace the one that has been cut away.
5. The surgeon now prepares the socket (glenoid fossa). First, holes are drilled into the shoulder blade that houses the socket. Then the surgeon prepares a special glue that is applied to the shoulder bone area. The glenoid (artificial cartilage) is inserted into the cavity using glue.
6. Now, the surgeon attends to the arm bone (humerus). A new stainless steel ball is inserted into the trunnion, which has already been attached to the top of the arm bone. The ball is held in place by a cage screw.
7. The ball at the top of the arm bone (humerus) is now inserted into the socket (glenoid) in the shoulder blade, as shown in image C. The surgeon then begins to close the incision. Tendons are re-attached together as they once were and the incision is stitched together, leaving a neat seam.