Dr. Williams is the chief shoulder surgeon at the University of Pennsylvania's Shoulder and Elbow Service and is also an Associate Professor in Penn's Department of Orthopedic Surgery. He was recently nominated to the Board of Directors of the America Academy of Orthopedic Surgeons (AAOS).
Shoulder1: Why did you choose to focus on the shoulder as a specialty?
Dr. Williams: Like most of us in medicine, I had a mentor – Dr. Charles Rockwood – where I did my residency who had a strong influence on me, and he happened to be a shoulder surgeon. I find it to be a very complicated joint; I find shoulder surgery fun. It's not often that you can operate on just one joint and do so many different operations. In other disciplines such as knee surgery, sports medicine, or joint replacement surgery, you may do primarily only a few different types of operations. Whereas shoulder surgery offers the opportunity to see everything from adolescent kids with instability to older people with arthritis that need shoulder replacement. Consequently, the gamut of things that I do in the operating room are as sublime as arthroscopic repairs of small rotator cuff tears to as significant as replacing the entire shoulder joint.
Shoulder1: What is your role at with the Shoulder & Elbow Service at Penn?
Dr. Williams: I am the chief of the shoulder and elbow service here at Penn and the Chief of Orthopaedic Surgery at Presbyterian Hospital. My practice is exclusively shoulder problems. My research areas of interest include biomechanics and kinematics of normal and prosthetic shoulders, the basic science of rotator cuff repairs, and the comparison of arthroscopic and open approaches in the management of shoulder instability and rotator cuff repairs.
Shoulder1: Do you find that your patients want to know about the latest technology for treating their injuries?
Dr. Williams: Most of them are pretty savvy with regard to whether or not they want arthroscopic or open surgery. I see a lot of patients with rotator cuff injuries or dislocating shoulders that come to me specifically because of their desire for an arthroscopic approach. Most of them know or at least have the impression that there are some advantages to arthroscopic surgery, that it's a newer technology.
Shoulder1: What are the differences between "open" and "arthroscopic" rotator cuff repair?
Dr. Williams: There are advantages and disadvantages to both. The advantages to arthroscopic rotator cuff are that you do minimal damage to the normal surrounding structures during your rotator cuff repair. In other words, you get right down to the rotator cuff area. You do everything that you would do in an open procedure, but you do it with minimal amount of damage to the surrounding tissues; the deltoid muscle, in particular. This translates into fewer deltoid muscle problems post-operatively.
You have less pain and scaring with arthroscopic techniques. As a result most patients get better from the standpoint of pain and the ability to move their arm around much quicker with the arthroscopic techniques than with the open techniques. My experience has been that the real advantages, from the patient's point of view, of arthroscopic techniques occur in the first 6 to 8 weeks. They have much less pain, and they feel they are over the operation much more quickly. If you were take a person that had a good result from an open rotator cuff repair and a good result from an arthroscopic repair and compare them in a year's time … it would be hard for you to tell the difference between the two. The big difference is in the first 6 or 8 weeks.
The disadvantages of arthroscopic repair include its technical difficulty, the fact that proficiency is partially volume driven, and the uncertainty with regard to post-operative healing rates. The best results following rotator cuff repair occur when the actual tendon heals to the bone permanently. We know that even in open surgery, depending upon the cuff tear size, there can be as few as 15-20% recurrence rates and as high as 50-60% recurrence rates at five years following rotator cuff repair. Similar data following arthroscopic cuff repair is not routinely available. This is a relative disadvantage that may pan out with further research.
Shoulder1: When is too much shoulder pain a sign of something more serious than, say tendonitis or muscle strain?
Dr. Williams: A lot of it depends on the circumstances. If somebody has a specific traumatic event, such as a "pop" in their shoulder while throwing, that hasn't gotten better after a few weeks, that may be a sign that something has torn. Conversely, pain associated with repetitive activity may indicate overuse tendonitis.
Shoulder1: What is the most difficult injury you have repaired where the patient recovered even better than expected?
Dr. Williams: I can remember a bicyclist about 45 years old who fell in a bicycle race. He broke his scapula with involvement of the glenoid fossa or socket. There were many pieces and we were fortunate enough to be able to piece it back together anatomically so he could return to bicycle racing.
Shoulder1: What do you see as your greatest professional accomplishment?
Dr. Williams: Maintaining a busy clinical practice while acting as a teacher and mentor to young physicians. I am involved in full-time academic medicine and also have a very busy clinical practice. It is sometimes difficult to balance the responsibilities of clinical practice and academic responsibilities, such as teaching and research. I believe I have done a reasonable job of balancing these responsibilities, although I am sure there are areas within which I could improve.
Shoulder1: You spoke of your efforts to build a state-of-the-art Digital OR at Penn. How will this new technology change surgery, both for patients and surgeons?
Dr. Williams: There are two aspects of the digital OR that we find intriguing. First is as it relates to the delivery of healthcare, the OR becomes more efficient. You spend less time in the operating room. The (OR staff is) more efficient with their time, and as a result your patient’s experience as is quicker and more efficient. Secondly, the digital OR is an excellent educational tool. It gives us the opportunity to capture on video various aspects of surgical technique and share those videos with interested students of Orthopaedic surgery anywhere in the world.