Complications after total shoulder arthroplasty - the Surgeon is the Method

 

The quest for ways to make shoulder arthroplasty safer for future patients continues through Shoulder Arthroplasty Research. Here are some things we know: 

(1) most shoulder arthroplasties turn out well for the patient, thus our greatest opportunities to learn come from studying failures

(2) it is insufficient to focus on the type of failure (e.g. glenoid component loosening, rotator cuff failure); rather we need to hone in on what could have been done differently at the primary arthroplasty to lower the risk of component or cuff failure - this can be thought of as actionable intelligence.

(3) we want to avoid the assumption that technologies such as 3D CT based planning, patient specific instrumentation, robotics, virtual reality, augmented reality will lower failure risk until their effectiveness in vivo has been rigorously demonstrated

(4) our attention falls on the surgeon and the elements of care that are under her/his control

A recent article, The effect of surgeon volume on complications after total shoulder arthroplasty: a nation-wide assessment, provides some actionable intelligence. The authors retrospectively queried the Pearl Diver Mariner database for the years 2010 to 2022. Their analysis included 155,560 patients having primary anatomic total shoulder arthroplasty, excluding those younger than 40 years, those who underwent revision arthroplasty, cases of bilateral arthroplasty, and cases with a history of fracture, infection, or malignancy.

They included cases performed by surgeons with a minimum of 10 cases. 

The 90th percentile for surgeon volume was determined to be 112 cases during the study period. Surgeons above the 90th percentile (n 340) operated on 68,531 patients, whereas surgeons below the 90th percentile (n 3038) operated on 87,029 patients. Surgeons in the high-volume group were significantly more likely to have completed a Shoulder and Elbow fellowship and less likely to have no fellowship training or fellowship training outside of Shoulder and Elbow or Sports Medicine. 

Low-volume surgeons operated on patients with higher baseline comorbidities. Here's my summary of their data.

After adjusting for age, gender, CCI, obesity, and tobacco use, high-volume surgeons experienced lower rates of medical complications including renal failure, anemia, and urinary tract infection. All-cause readmission, reoperation at 90 days, and reoperation at 1 year were significantly lower among high-volume surgeons. Cases performed by high-volume surgeons exhibited lower rates of all complications including prosthetic joint infection and periprosthetic fracture. Here's my summary of their data. NB an odds ratio <1 means that cases operated by high volume surgeons had a lower rate of the complication than low volume surgeons.

Finally, the authors found that the proportion of shoulder arthroplaties performed by high volume surgeons has been decreasing with time.

Comment: This study appropriately puts the focus on the surgeon - the individual that decides which treatment is best suited for each patient, carries out the surgery, and manages the aftercare. In other words, the surgeon controls the modifiable variables for each patient. The surgeon is the method.

The authors characterize the surgeon in three dimensions: (1) case volume, (2) fellowship, and (3) the comorbidites of the patients the surgeon selects to have total shoulder arthroplasty. They then go on to compare complications for surgeons performing ≥ 112 arthroplasties to those performing < 112. 

Thus the data available are ripe for a multivariable analysis (MVA) characterizing the relationship among these variables - individually or in combination - to the occurrence of medical and surgical complications. Without such an analysis we cannot know the relative importance of each of these dimensions.

Let's look at each of these characteristics:

Surgeon case volume: One of the big questions in orthopaedics is whether more is more, i.e do we continue to get a bit better with each case, or is there a threshold above which we are "good"? In this light it might be more informative to characterize surgeon case volume as the number of cases rather an whether they exceeded a threshold for qualification as "high volume"?  This would get around the problem of having a surgeon performing 111 cases designated as "low volume" whereas if the surgeon had done one more case he/she would suddenly become "high volume". On reading this paper, a patient might ask "should I travel four hours to have an arthroplasty by a surgeon who has done 120 cases rather than sticking with my local surgeon who has done 110?  Numbers may be better than categories. An MVA should be able to sort this out.

Fellowship: The additional year of specialized training afforded by fellowship exposes trainees to a greater case volume and breadth. High volume surgeons were more than twice as likely to have taken a shoulder fellowship; however, fewer than 30% of high volume surgeons took a shoulder fellowship. As a result we do not know from the data presented whether taking a shoulder fellowship results in a significantly greater arthroplasty practice volume or whether taking a shoulder fellowship reduces the surgeon's complication rate. An MVA should be able to sort this out.

Comorbidities: The patient population of high-volume surgeons was significantly healthier, i.e., comorbidities as reflected by the Charlson Comorbidity Index were lower in patients operated by higher volume surgeons (perhaps because experience teaches to think carefully before offereing elective surgery to patients who are ill or perhaps high volume surgeons operate in outpatient centers that exclude sick patients). The question is whether a shoulder fellowship or being a high volume surgeon enables safer surgery on patients with comorbidites. An MVA should be able to sort this out.

Complications: This article presents data on medical and surgical complications in terms of odds ratios, but does not present data on the rate of each complication. In an MVA it may be easier to characterize complications in terms of their rates.

Arthroplasty choice: The authors point out that "distinctions between anatomic and reverse shoulder arthroplasty were not made because of limitations associated with CPT coding". This is an important shortcoming of the analysis, because experienced (and perhaps fellowship-trained shoulder surgeons), may be better at deciding which patients are the best candidates for each procedure in terms of avoidance of medical and surgical complications.  

Incremental value of each case: Numbers are not the only important thing. How much the surgeon learns from each case depends in large part on whether the sugeon conducts an After Action Report (AAR) after each case. An AAR is a structured process used to review the case to identify what happened, what went well, and what could be improved in future cases. We can assume that a 100 case surgeon who routinely conducts AARs will have better outcomes than a120 case surgeon who goes on to the next case without introspection. This is important because most shoulder arthroplasties are not operated on by high volume surgeons.

We can do a better job of helping our patients avoid problems.

Fresh Grizzly Bear Footprint

Devil's Gap, Alberta

Photo by Laura Matsen, M.D

8/23/2025

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Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link)
Shoulder rehabilitation exercises (see this link).

The academic power of a shoulder fellowship.

Shoulder fellowships are the engine driving the future of shoulder surgery.

Taking the University of Washington's fellowship as but one example, 60% of the peer reviewed shoulder publications were powered by the shoulder fellows (see chart below). Without their curiosity, energy, dedication, and scientific skill, the program's academic productivity would not be what it is today.

25% of the graduates of this fellowship have university faculty positions across North America and beyond. Many of the others are academically active in non-university settings from which they continue to conduct clinically relevant research as well as teaching students, residents, fellows, and practicing surgeons.

In looking over some of the most recent publications, once can see not only the authorships of the fellows (in bold), but also evidence of their support of research by students (in red) and orthopaedic residents (in green), many of whom will be pursing shoulder fellowships.

We can all be grateful to the 33 ASES-recognized Shoulder and Elbow Fellowship Programs for their huge role in assuring progressively improving quality of care for patients with disabling shoulder and elbow conditions.

You can support cutting edge shoulder research that is leading to better care for patients with shoulder problems, click on this link.

Follow on twitter: https://twitter.com/shoulderarth
Follow on facebook: click on this link
Follow on facebook: https://www.facebook.com/frederick.matsen
Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link).
Shoulder rehabilitation exercises (see this link).

The Future of American Shoulder and Elbow Surgery - the University of Washington Fellowship

This week, 24 of the brightest and best applicants for shoulder and elbow fellowship were invited and accepted the opportunity to interview for the University of Washington's advanced clinical experience in our specialty.

This group of women and men is truly outstanding - one of the best we seen since starting our fellowship in 1988. Two of these candidates will join our 57 fellowship alumni who are now practicing shoulder and elbow surgery across the country - from Seattle to Miami, from SanDiego to Portsmouth, New Hampshire. Almost all of our graduates are members of the American Shoulder and Elbow Surgeons (ASES). One-quarter of our graduates have been recruited to university faculty positions.

Our goal is to enable our fellows to master advanced skills in diagnosis and surgical management of both common and rare conditions that prevent patients from enjoying their lives. In addition, we will provide opportunities for them to engage in cutting edge research investigating some of the major questions faced by our specialty, such as
(1) when is rotator cuff repair not in the best interest of a patient with a cuff tear?
(2) what evidence should guide treatment for irreparable rotator cuff tears?
(3) what can be offered to a patient with arthritis who wishes to pursue activities beyond what is recommended for a conventional total shoulder?
(4) how important is it to "correct" glenoid retroversion in performing shoulder arthroplasty?
(5) is there a practical alternative to the reverse total should for patients with cuff tear arthropathy and retained active elevation?
(5) how can surgeons monitor the quality of their practice outcomes to identify what is working and what is not?
(6) how can we avoid unnecessary expenses of imaging - a cost that consumes much of the resource spent on shoulder and elbow care?
(7) how can we evaluate the many new orthopaedic implants and products brought to market each year to determine if their increased cost results in increased benefit to our patients?
(8) how can we make shoulder and elbow surgery safer from the risk of infection?

We are excited to be tackling these and other 'big questions'. We are excited to have the partnership of our fellows, who help us and who end out teaching us as well. For sure, the future is brighter because of them.


Here are the publications of our core faculty:
Jason Hsu
Frederick Matsen
Winston Warme
Albert Gee
Jonah Hebert-Davies

Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link).
Shoulder rehabilitation exercises (see this link).


Here are some links about our fellowship and our area:

The University of Washington Shoulder and Elbow Fellowship
Life in Seattle
Beautiful Seattle
How to find the best hikes around Seattle
The Pacific Northwest




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The Future of Shoulder Surgery.

This morning, we completed our interviews of 29 candidates for the Shoulder and Elbow Fellowship at the University of Washington. This group of candidates is truly outstanding - one of the best we seen since starting our fellowship in 1988. Two of these young men and women will join our 55 fellowship alumni who are now practicing shoulder and elbow surgery across the country - from Seattle to Miami, from SanDiego to Portsmouth, New Hampshire. Almost all of our graduates are members of the American Shoulder and Elbow Surgeons (ASES). One-quarter of our graduates have been recruited to university faculty positions. 

Our goal is to enable our fellows to master advanced skills in diagnosis and surgical management of both common and rare conditions that prevent patients from enjoying their lives.  In addition, we will provide opportunities for them to engage in cutting edge research investigating some of the major questions faced by our specialty, such as
(1) when is rotator cuff repair not in the best interest of a patient with a cuff tear?
(2) what can be offered to a patient with arthritis who wishes to pursue activities beyond what is recommended for a conventional total shoulder?
(3) how can surgeons monitor the quality of their practice outcomes to identify what is working and what is not?
(4) how can we avoid unnecessary expenses of imaging - a cost that consumes much of the resource spent on shoulder and elbow care?
(5) how can we evaluate the many new orthopaedic implants and products brought to market each year to determine if their increased cost results in increased benefit to our patients?
(6) how can we make shoulder and elbow surgery safer from the risk of infection?

We are excited to be tackling these and other 'big questions'. We are excited to have the partnership of our fellows, who help us and who end out teaching us as well. For sure, the future is brighter because of them.

Here are the publications of our core faculty:

    Jason Hsu

    Frederick Matsen

    Winston Warme

    Albert Gee

    Jonah Hebert-Davies

Here are some of the approaches we share with our fellows:

How to get the most information out of plain x-rays (see this link)

Managing irrerparable rotator cuff tears (see this link)

The cuff tear arthropathy arthroplasty (see this link).

A straightforward approach to reverse total shoulder arthroplasty (see this link).

Shoulder rehabilitation exercises (see this link).

How to do a robust anatomic totals shoulder (see this link).

The ream and run technique for active individuals (see this link) (see email below from today).

Here are some links about our fellowship and our area:

The University of Washington Shoulder and Elbow Fellowship

Life in Seattle

Beautiful Seattle

How to find the best hikes around Seattle

The Pacific Northwest

You can support cutting edge shoulder research that is leading to better care for patients with shoulder problems, click on this link.

Follow on twitter: https://twitter.com/shoulderarth

Follow on facebook: click on this link

Follow on facebook: https://www.facebook.com/frederick.matsen

Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

The future of shoulder surgery

Shoulder and elbow surgery is 75% knowledge, 75% skill and 75% art. It cannot be learned from books or labs alone; rather, like a new language, acquiring mastery requires immersion in a comprehensive experience focused on the evaluation and management of patients and a philosophy of practice. To provide this opportunity to selected young orthopaedic surgeons, we are interviewing candidates for the University of Washington Shoulder and Elbow Fellowship. Ours is a one year advanced clinical and academic experience that enables two highly qualified orthopaedists to hone their skills as shoulder and elbow surgeons, as investigators and as educators.

Our fellowship started in 1988, making it one of the longest standing advanced clinical experiences in our field - this will be our 35th anniversary! Our 56 graduates now practice shoulder and elbow surgery across the country - from Seattle to Miami, from SanDiego to Portsmouth, New Hampshire. Almost all of our graduates are members of the American Shoulder and Elbow Surgeons (ASES). One-quarter of our graduates have been recruited to university faculty positions. 

Here are a few of our "senior" fellows, perhaps you recognize some of them.

From left to right, Steve Lippitt, John Sidles, Mark Lazarus, Kevin Smith, David Duckworth, the late Doug Harryman, Michael Pearl, Rick Matsen, Dean Ziegler, Craig Arntz, and Tony Romeo. A complete list of our alumni can be seen in this link.

Our goal is to enable our fellows to master advanced skills in diagnosis and surgical management of both common and rare conditions that prevent patients from enjoying their lives.  In addition, we will provide opportunities for them to help answer some of the major questions faced by our specialty, such as
(1) when is rotator cuff repair not in the best interest of a patient with a cuff tear?
(2) what can be offered to a patient with arthritis who wishes to pursue activities beyond what is recommended for a conventional total shoulder?
(3) how can surgeons monitor the quality of their practice outcomes to identify what is working and what is not?
(4) how can we avoid unnecessary expenses of imaging - a cost that consumes much of the resource spent on shoulder and elbow care?
(5) how can we evaluate the many new orthopaedic implants and products brought to market each year to determine if their increased cost results in increased benefit to our patients?
(6) how can we make shoulder and elbow surgery safer from the risk of infection?

We are excited to be tackling these and other 'big questions'. We are excited to have the partnership of our fellows, who help us and who end out teaching us as well. For sure, the future is brighter because of them.

Here are the publications of our core faculty

    Jason Hsu

    Frederick Matsen

    Winston Warme

    Albert Gee

    Jonah Hebert-Davies

Here are some of the approaches we share with our fellows

How to get the most information out of plain x-rays (see this link)

Managing irrerparable rotator cuff tears (see this link)

How to do a robust anatomic totals shoulder (see this link).

The ream and run technique for active individuals (see this link).

The cuff tear arthropathy arthroplasty (see this link).

A straightforward approach to reverse total shoulder arthroplasty (see this link).

Here are some links that may be of interest:

The University of Washington Shoulder and Elbow Fellowship

Life in Seattle

Beautiful Seattle

How to find the best hikes around Seattle

The Pacific Northwest

Follow on twitter: https://twitter.com/shoulderarth

Follow on facebook: https://www.facebook.com/frederick.matsen

Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

The Shoulder and Elbow Fellowship at the University of Washington - insuring the future of our specialty

For an recent update of this post, please see this link.

Shoulder and elbow surgery is 75% knowledge, 75% skill and 75% art. It cannot be learned from books or labs alone; rather, like a new language, acquiring mastery requires immersion in a comprehensive experience focused on the evaluation and management of patients and a philosophy of practice. To provide this opportunity to selected candidates, we will soon be interviewing candidates for the University of Washington Shoulder and Elbow Fellowship. This is a one year advanced clinical and academic experience that enables two highly qualified orthopaedists to hone their skills as shoulder and elbow surgeons, as investigators and as educators.

Our fellowship started in 1988, making it one of the longest standing advanced clinical experiences in our field - this will be our 32nd anniversary! Our graduates now practice shoulder and elbow surgery across the country - from Seattle to Miami, from SanDiego to Portsmouth, New Hampshire. The two candidates paired with us by the American Shoulder and Elbow Surgeons fellowship matching program will become the 55th and 56th University of Washington Shoulder and Elbow Fellows.

Our goal is to enable our fellows to master advanced skills in diagnosis and surgical management of both common and rare conditions that prevent patients from enjoying their lives.  In addition, we will provide opportunities for them to help answer some of the major questions faced by our specialty, such as
(1) when is rotator cuff repair not in the best interest of a patient with a cuff tear?
(2) what can be offered to a patient with arthritis who wishes to pursue activities beyond what is recommended for a conventional total shoulder?
(3) how can surgeons monitor the quality of their practice outcomes to identify what is working and what is not?
(4) how can we avoid unnecessary expenses of imaging - a cost that consumes much of the resource spent on shoulder and elbow care?
(5) how can we evaluate the many new orthopaedic implants and products brought to market each year to determine if their increased cost results in increased benefit to our patients?
(6) how can we make shoulder and elbow surgery safer from the risk of infection?

We are excited to be tackling these and other 'big questions'. We are excited to have the partnership of our fellows, who help us and who end out teaching us as well. For sure, the future is brighter because of them.

Half of our graduates have earned admission to the prestigious American Shoulder and Elbow Surgeons society. One of our alumni, Tony Romeo, is its immediate past president. Here are a few of our older fellows, perhaps you recognize some of them.

From left to right, Steve Lippitt, John Sidles, Mark Lazarus, Kevin Smith, David Duckworth, the late Doug Harryman, Michael Pearl, Rick Matsen, Dean Ziegler, Craig Arntz, and Tony Romeo.

To learn more about our fellowship and our alumni, see this link and this link.

For information on life in Seattle, check out this link and this one and this on beautiful Seattle.

The future of shoulder surgery - the shoulder fellowship

Shoulder and elbow surgery is 75% knowledge, 75% skill and 75% art. It cannot be learned from books or labs alone; rather, like a new language, acquiring mastery requires immersion in a comprehensive experience focused on the evaluation and management of patients and a philosophy of practice. To provide this opportunity to selected candidates, we are now interviewing candidates for the University of Washington Shoulder and Elbow Fellowship. This is a one year advanced clinical and academic experience that enables two highly qualified orthopaedists to hone their skills as shoulder and elbow surgeons, as investigators and as educators.

Our fellowship started in 1988, making it one of the longest standing advanced clinical experiences in our field - this is our 31th anniversary! Our graduates now practice shoulder and elbow surgery across the country - from Seattle to Miami, from SanDiego to Portsmouth, New Hampshire. The two candidates paired with us by the American Shoulder and Elbow Surgeons fellowship matching program will become the 53rd and 54st University of Washington Shoulder Fellows.

Our goal is to enable our fellows to master advanced skills in diagnosis and surgical management of both common and rare conditions that prevent patients from enjoying their lives.  In addition, we will provide opportunities for them to help answer some of the major questions faced by our specialty, such as
(1) when is rotator cuff repair not in the best interest of a patient with a cuff tear?
(2) what can be offered to a patient with arthritis who wishes to pursue activities beyond what is recommended for a conventional total shoulder?
(3) how can surgeons monitor the quality of their practice outcomes to identify what is working and what is not?
(4) how can we avoid unnecessary expenses of imaging - a cost that consumes much of the resource spent on shoulder and elbow care?
(5) how can we evaluate the many new orthopaedic implants and products brought to market each year to determine if their increased cost results in increased benefit to our patients?
(6) how can we make shoulder and elbow surgery safer from the risk of infection?

We are excited to be tackling these and other 'big questions'. We are excited to have the partnership of our fellows, who help us and who end out teaching us as well. For sure, the future is brighter because of them.

Half of our graduates have earned admission to the prestigious American Shoulder and Elbow Surgeons society. One of our alumni, Tony Romeo, is the immediate past president. Here are a few of our older fellows, perhaps you recognize some of them.

From left to right, Steve Lippitt, John Sidles, Mark Lazarus, Kevin Smith, David Duckworth, the late Doug Harryman, Michael Pearl, Rick Matsen, Dean Ziegler, Craig Arntz, and Tony Romeo.

To learn more about our fellowship and our alumni, see this link and this link.

For information on life in Seattle, check out this link and this one and this on beautiful Seattle.

The future of shoulder and elbow surgery

Today we have the great pleasure of interviewing candidates for the University of Washington Shoulder and Elbow Fellowship. This is a one year advanced clinical and academic experience that enables two highly qualified orthopaedists to hone their skills as shoulder and elbow surgeons, as investigators and as educators.

Our fellowship started in 1988, making it one of the longest standing advanced clinical experiences in our field - this is our 30th anniversary! Our graduates now practice shoulder and elbow surgery across the country - from Seattle to Miami, from SanDiego to Portsmouth, New Hampshire.

Our goal is to enable our fellows to master advanced skills in diagnosis and surgical management of both common and rare conditions that prevent patients from enjoying their lives.  In addition, we will provide opportunities for them to help answer some of the major questions faced by our specialty, such as
(1) when is rotator cuff repair not in the best interest of a patient with a cuff tear?
(2) what can be offered to a patient with arthritis who wishes to pursue activities beyond what is recommended for a conventional total shoulder?
(3) how can surgeons monitor the quality of their practice outcomes to identify what is working and what is not?
(4) how can we avoid unnecessary expenses of imaging - a cost that consumes much of the resource spent on shoulder and elbow care?
(5) how can we evaluate the many new orthopaedic implants and products brought to market each year to determine if their increased cost results in increased benefit to our patients?
(6) how can we make shoulder and elbow surgery safer from the risk of infection?

We are excited to be tackling these and other 'big questions'. We are excited to have the partnership of our fellows, who help us and who end out teaching us as well. For sure, the future is brighter because of them.

To learn more about our fellowship and our alumni, see this link. To see the beautiful environment in which we work, see this link.

Shoulder Fellowship: the future of our specialty.

The American Shoulder and Elbow Surgeons, our national organization, is concluding this year's matching system by which the 58 young orthopaedic surgeons wishing advanced training in shoulder and elbow surgery will be paired with the 27 programs offering 42 fellowship positions. As can be seen from these numbers, there is strong competition for the available fellowships.

At the University of Washington we offer two fellowship positions each year and have just concluded our interviews with 21 of the most competitive candidates for our program. Those paired with us by the fellowship matching program will become the 49th and 50th University of Washington Shoulder Fellows. These surgeons will spend a year with us learning, teaching, caring for patients, discovering new knowledge and enjoying the beautiful Pacific Northwest (see this link).

Our fellowship was started 30 years ago and has produced truly outstanding shoulder surgeons who have now established robust practices both near and far, including Vancouver, New Hampshire, Miami, and San Diego. They have made and continue to make meaningful contributions to the evaluate and management of individuals troubled with shoulder and elbow problems. Half of our graduates have earned admission to the prestigious American Shoulder and Elbow Surgeons society. One of our alumni, Tony Romeo, is the current president. Here are a few of our older fellows, perhaps you recognize some of them.

From left to right, Steve Lippitt, John Sidles, Mark Lazarus, Kevin Smith, David Duckworth, the late Doug Harryman, Michael Pearl, Rick Matsen, Dean Ziegler, Craig Arntz, and Tony Romeo.

We are most grateful to the alumni of our fellowship for their research - which includes many foundational contributions to the literature, for their help in the care of our patients, and for their ongoing work to make tomorrow's patient care better than yesterday's.

We invite you to learn more about our fellowship by visiting this link.

For information on life in Seattle, check out this link and this one.

Shoulder fellowship at the University of Washington

Shoulder and elbow surgery is 75% knowledge, 75% skill and 75% art. It cannot be learned from books or labs alone; rather, like a new language, acquiring mastery requires immersion in a comprehensive experience focused on the evaluation and management of patients and a philosophy of practice. Our program is now almost 30 years old, one of the oldest shoulder and elbow fellowships in the world. We have a growing legacy outstanding alumni of the one-year experience through which we strive to provide such an opportunity for those who aspire to be the future leaders in this field. We are most grateful to the alumni of our fellowship for their research - which includes many foundational contributions to the literature, for their help in the care of our patients, and for their ongoing work to make tomorrow's patient care better than yesterday's.

You can learn more about our fellowship by visiting this link.

This seems a fitting time to show a photo of some of our past fellows, perhaps you've heard of them.

From left to right, Steve Lippitt, John Sidles, Mark Lazarus, Kevin Smith, David Duckworth, the late Doug Harryman, Michael Pearl, Rick Matsen, Dean Ziegler, Craig Arntz, and Tony Romeo.

The University of Washington Shoulder/Elbow Fellowship - our contribution to the future of the specialty

Shoulder and elbow surgery is 75% knowledge, 75% skill and 75% art. It cannot be learned from books or labs alone; rather, like a new language, acquiring mastery requires immersion in a comprehensive experience focused on the evaluation and management of patients and a philosophy of practice. Our program is now almost 30 years old, one of the oldest shoulder and elbow fellowships in the world. We have a growing legacy outstanding alumni of the one-year experience through which we strive to provide such an opportunity for those who aspire to be the future leaders in this field. We are most grateful to the alumni of our fellowship for their research - which includes many foundational contributions to the literature, for their help in the care of our patients, and for their ongoing work to make tomorrow's patient care better than yesterday's.

You can learn more about our fellowship by visiting this link.

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Consultation for those who live a distance away from Seattle.

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.

See the countries from which our readers come on this post.

The ream and run - three videos for patients and shoulder fellowship candidates

The ream and run procedure is of increasing interest to highly active patients wishing to avoid the potential risks of a plastic glenoid component. The procedure is also of interest to the next generation of shoulder surgeons. At the University of Washington we recently had the great pleasure of interviewing a group of outstanding candidates for our one year shoulder fellowship. They expressed interest in seeing some video regarding the ream and run procedure so we share three of them here.

the ream and run procedure

activities that some patients have been able to perform after the ream and run

hitting the bag after the ream and run.

We also remind prospective ream and run patients and surgeons that this procedure is not for everyone and that the recovery of the biologic glenoid arthroplasty takes time as shown here.

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Consultation for those who live a distance away from Seattle.

Check out the new Shoulder Arthritis Book - click here.

Click here to see the new Rotator Cuff Book

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.

See the countries from which our readers come on this post.

The growing legacy of the Shoulder and Elbow Program at the University of Washington

Stimulated by the 5-month experience that Dr. Matsen had with Dr. Neer, in 1988 we decided to offer a one-year experience to those interested in advanced training in shoulder and elbow. This was one of the first one-year shoulder fellowships in the world. Our first fellow was the late Douglas T. Harryman, who made many enduring contributions to our understanding of surgical approaches and the mechanics of the shoulder. He was also a pioneer in arthroscopic approaches to rotator cuff disease, instability and the management of the stiff shoulder.

Forty-four orthopaedic surgeons have completed this year long fellowship, returning to academic and private practices across the globe: from David Duckworth in Sydney, Australia to Moby Parsons in New Hampshire, from Ed Weldon in Oahu, Hawaii to Richard Boorman in Calgary, Canada, from Richard Rozencwaig in Miami, Florida to Ben DuBois in San Diego, California, and from Craig Arntz in Seattle to Yong Girl Rhee in Seoul, Korea. This fall we will match with two individuals who will complete the fellowship in 2018, becoming the 49th and the 50th graduates of our program.

Over half of our fellowship graduates have earned membership in the American Shoulder And Elbow Surgeons group that Dr. Matsen helped found along with Drs. Neer, Rockwood, Cofield, Hawkins and Jobe in 1982. Our most recent fellow to join ASES is Joe Lynch who was granted membership this year. Our former fellow, Tony Romeo from Rush, will become president of ASES next year.

We are overwhelmed by the continuing accomplishments of our graduates, whether it be in national leadership, outstanding research contributions, innovations in orthopaedic procedures and devices, or in the excellence of their patient care.

Our growing academic legacy is documented in well over 200 publications in the premier orthopaedic journals and several texts, including Rockwood and Matsen’s The Shoulder, which is nearing publication of its 5th Edition with Dr. Matsen as the senior editor. These publications would not have been possible without the substantial contributions and authorship of our fellows. Again this year our fellows are actively involved in research that will permanently change the evaluation and management of patients with shoulder and elbow problems.

The legacy of our fellowship also includes foundational concepts that have been developed here at the University of Washington by Drs. Warme, Hsu, Gee, Matsen and our fellows. Some of these are listed below.

Treatment outcomes
*The key to evaluating the outcome of surgery is a quick, sensitive, validated tool by which the patient can document the status of his/her shoulder before and sequentially after treatment without having to return to the office = the Simple Shoulder Test (commonly know as the SST).

*The result of a treatment is determined by the 4 Ps: the characteristics of the patient, the shoulder problem being treated, the procedure used to treat the problem, and the physician rendering the treatment for the patient.

*The value of an evaluation and management approach can be defined as the benefit to the patient divided by its cost. For example if a preoperative CT scan of an arthritic shoulder does not lead to an improved outcome for the patient, it is of less value than less expensive and less irradiating plain films.

Glenohumeral stability
*The primary stabilizing mechanism for the shoulder is concavity compression – the compressive action of the cuff and deltoid forces centering the humeral head in the glenoid concavity throughout the range of motion, including the many positions in which the ligaments are lax. Treatment of instability requires restoration of this mechanism.

*An anatomic repair of the Bankart lesion is sufficient for the management of most cases of recurrent glenohumeral instability. Bone transfers, such as the Latarjet procedure or iliac crest graft, have increased complication rates and morbidity – for those reasons they are reserved for cases of failed anatomic repairs or cases of massive glenoid bone deficiency.

*Pain pump infusion of local anesthetics is not necessary in the management of glenohumeral instability and can lead to the complication of chondrolysis.

Sternoclavicular joint
*The unstable SC joint can be safely reconstructed by an allograft weave.

Rotator cuff
*An intact supraspinatus is not necessary to initiate abduction.

*The outer aspect of the proximal humeral convexity normally contacts and articulates with the concavity of the coracoacromial arch, providing stability resisting superiorly directed forces. This contact is not ‘impingement’. Sacrifice of the CA arch by acromioplasty can lead to anterosuperior escape and pseudoparalysis. The cuff muscles are not ‘head depressors’, but rather ‘head compressors’.

*In patients with a symptomatic irreparable cuff tear and an intact coracoacromial arch, comfort and function can often be improved by a smooth and move procedure that removes roughness from the proximal humeral convexity and restores full passive range of motion without attempting a cuff repair or graft.

*Acromioplasty is unnecessary in the treatment of cuff disease.

*Recent ‘advances’ in rotator cuff repair techniques have not led to improved clinical results or to reduced rates of retear. The integrity of the cuff repair is not strongly related to the clinical outcome of the surgery.

Arthritis
*CT scans are unnecessary in the evaluation of most cases of glenohumeral arthritis. The key image is the ‘truth view’ – a standardized axillary view taken with the arm in a position of functional elevation. This view shows the glenoid version, the glenoid type, and the degree of posterior functional decentering of the humeral head on the glenoid.

*Lesser tuberosity osteotomy (LTO) is not necessary to gain access to the glenoid or to achieve restoration of subscapularis integrity. LTO has the disadvantage of compromising the ability to get a secure proximal press fit of the stem with impaction grafting.

*Metal-backed glenoid components have a higher failure rate than all polyethylene pegged glenoid components.

*”Correction” of glenoid retroversion is not a priority in shoulder arthroplasty; posterior decentering can be effectively managed by an anteriorly eccentric humeral head component and rotator interval plication.

*Avoiding the use of a guide wire enables the surgeon to ream the glenoid to a single concavity with the removal of a minimal amount of bone. 3D planning based on CT scans and patient specific instrumentation add cost and radiation without documented benefit to the patient.

*Bone ingrowth, porous coating, and trabecular metal are unnecessary for the fixation of the humeral component; robust, bone-conserving and durable fixation of the prosthesis can be reliably achieved by impaction autografting using bone harvested from the resected humeral head.

*Impaction grafting facilitates the intra-operative adjustment of the height, version, and angle of the humeral prosthesis by selective addition and positioning of the graft.

*The use of small diameter humeral stems along with impaction grafting avoids the stress riser at the tip of the prosthesis and avoids the risk of incomplete seating of the humeral stem due to incarceration of the prosthetic tip in the diaphysis.

* Fixation of the humeral stem with impaction grafting greatly facilitates revision should that become necessary, eliminating the need to remove cement and minimizing the risk of fracture and the need for humeral osteotomy.

*Excellent functional restoration for the arthritic shoulder can be achieved without the use of a prosthetic glenoid component. The ream and run procedure provides a non-prosthetic approach to glenoid arthroplasty, avoiding the potential risks associated with plastic and bone cement.

Cuff tear arthropathy
*In patients with active elevation above 90 degrees and without anterosuperior escape, comfort and function can be improved using a CTA (cuff tear arthropathy) prosthesis that may be a preferable option (in comparison to a reverse total shoulder) for patients desiring heavy physical use of the shoulder or those who have a high fall risk.

Reverse total shoulder
*Prostheses that enable immediate robust glenoid fixation with a large central screw and lateralization of the glenosphere provide secure glenohumeral stability and minimize the risk of scapular notching and polyethylene failure.

*If the tuberosities are intact, secure humeral component fixation can be achieved with impaction autografting of a monoblock stem.

Periprosthetic infections
*Propionibacterium are normal inhabitants of the dermal sebaceous glands where they cannot be reached by epidermal skin preparation and from where they are released into the wound by skin incisions or by needles used for injection.

*Propionibacterium periprosthetic infections present in a “stealth” mode, rather than in the “obvious” mode characteristic of hip and knee periprosthetic infections.

*Propionibacterium are the most common organisms to be recovered from failed arthroplasties. They can only be reliably recovered if special culture techniques are used and if the cultures are observed for three weeks.

*Ceftriaxone and Vancomycin are preferred to Cephazolin or Clindamycin for preoperative prophylaxis due to the evolving sensitivity profile of Propionibacterium.

*A single-stage exchange to an impaction allografted hemiarthroplasty is usually sufficient for the management of a periprosthetic infection with Propionibacterium.


We hope this summary provides a useful view of our growing legacy. While we have made some substantial contributions to the foundation of knowledge on which shoulder surgery is practiced, there are many more opportunities ahead.

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Consultation for those who live a distance away from Seattle.

Check out the new Shoulder Arthritis Book - click here.

Click here to see the new Rotator Cuff Book

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You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

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The Future of Shoulder Surgery - the UW Shoulder Fellowship

Yesterday we had the pleasure to interview 16 most outstanding candidates for the 2015-6 Shoulder Fellowship at the University of Washington.  Most of them were able to make dinner at our home the night before.

At the Saturday interviews, our suspicions were  confirmed: these are the strongest candidates we've seen for many years. The future of shoulder surgery is in good hands!

The interview process was even more special because the interviewees had the chance to meet our two new faculty members, Albert Gee, who did his fellowship at the Hospital for Special Surgery, and Jason Hsu, who is completing his fellowship at Washington University in St Louis. Albert and Jason will bring new clinical and investigative dimensions to the UW Shoulder Team and make our fellowship experience even stronger.

More about our fellowship and faculty can be seen here.