Shoulder instability plagues millions worldwide, causing pain, loss of mobility, and frustration. Damage to the ligaments that hold the arm in the shoulder socket can cause the condition, which allows the shoulder to dislocate or subluxate frequently. Moreover, patients who have the joint operated on often find themselves with a stiff, painful shoulder. Dr. Jon Warner is all-too-familiar with shoulder instability and the possibility of post-operative stiffness. Dr. Warner has worked with shoulder problems for more than 15 years and has specialized in instability and stiffness.
Dr. Warner's work has centered around biomechanical analysis of the shoulder joint to better analyze and diagnose shoulder problems. Additionally, he has continued to investigate better arthroscopic techniques to allay the pain and stiffness patients experience after surgery. At Harvard, Dr. Warner founded the Shoulder Biomechanics Group, a think-tank for better diagnosis, visualization and analysis of the shoulder joint.
Before moving to Boston in 1998, Dr. Warner worked in Pittsburgh for eight years, serving as an associate professor, assistant director of the Center for Sports Medicine, and co-director of the Shoulder Research Laboratory at the University of Pittsburgh. He now serves as chief of the Harvard Shoulder Service at Harvard University and holds offices at Massachusetts General Hospital and Brigham and Women's Hospital in Boston. He has authored more than 60 peer review publications, 150 book chapters, and four books, and has been the recipient of more than 30 awards for his work with shoulders.
Shoulder1: There are countless specialties within medicine. What attracted you to orthopedics?
Dr. Warner: I became interested in this area based on my experience as an athlete, as well as my own personal injuries. I was also drawn to it due to the perception that it involved active problem solving and spatial recognition, like three-dimensional puzzle building.
Shoulder1: What shoulder ailment did you suffer from, and how did this affect your work?
Dr. Warner: I had an unstable shoulder, for which I underwent surgery. After the surgery, however, it became too tight and I lost range of motion. Subsequently, I required release of my stiff shoulder. Therefore, I had the patient perspective of not only going through surgery, but also seeing the management problems affecting my physicians and, in some cases, their lack of knowledge. I was impressed by the lack of the precision of some of these approaches to management of shoulder problems. My own experiences as a patient gave me the desire and drive to improve the standard of care for these conditions. For this reason, I developed my method of arthroscopic capsular release, and why I continue to find these patients not only the most challenging, but also the most rewarding.
Shoulder1: Like you, many people suffer from stiff shoulders. What are the most common causes for shoulder stiffness?
Dr. Warner:Shoulder stiffness occurs either as a primary or secondary disease. In the former case, it is called idiopathic adhesive capsulitis and it affects more women than men, diabetics four times more often than non-diabetics. In the latter case, it occurs after surgery or trauma.
Shoulder1: Your stiff shoulder set in after surgery. What causes this to happen?
Dr. Warner: In a post-surgical setting, it can occur if the shoulder is immobilized too long or if a surgery "over-tightens" the shoulder.
Shoulder1: You designed your own technique for arthroscopic capsular release. Could you explain this?
Dr. Warner: The procedure is designed for patients with stiff shoulders. It allows the surgeon to release adhesions "from the inside" using the arthroscope so that dissection is minimized. This technique allows complete access to the shoulder joint without the need for large incisions. The contracted and scarred tissue is released with either an electrocautery device or a radiofrequency energy wand. This allows the shoulder to rotate freely. The procedure is done under local anesthesia, using what's known as an "indwelling interscalene catheter." This device numbs the nerves to the arm as they come out of the neck. This anesthesia technique not only allows for surgery but also provides lasting pain relief for the first two days after the surgery. During this time, the therapist can perform passive motion on the repaired shoulder to facilitate range of motion.
Shoulder1: Your work at Harvard has led you to develop the Shoulder Biomechanics Group. Could you give an overview of what that group does?
Dr. Warner: The Shoulder Biomechanics Group is a group of physicians and scientists who attempt to address clinically relevant research questions in the form of scientific study projects. I organized this group in order to facilitate exchange of ideas from individuals with different areas of expertise, so that together we might be able to find some answers for the difficult problems that affect the shoulder. Our area of research has involved three-dimensional visualization of tendon repairs, bony structure anatomy as it relates to rotator cuff repair, development of landmarks to allow for more accurate reconstruction of shoulder fractures, and the development of tendon transfers to reconstruct tendon tears in the shoulder. This group includes a Ph.D. in biomechanical engineering, several students studying engineering at MIT, several postgraduate fellows in shoulder surgery, and a number of technicians and medical students. These individuals represent many different countries and, to date, they have included: Turkey, Hong Kong, Columbia, Finland, Scotland, England, and Germany.
Shoulder1: With the SBG, you have designed a robotic model that demonstrates shoulder function. How will this work, and how will it help doctors diagnose and treat problems within the joint?
Dr. Warner: So far, the robot model is on the drawing board. The essence of this plan is to design a model that allows surgical procedures to be performed and then permits analysis of the mechanics created in the shoulder. In this way, we will better understand which operation seems to be better for instability surgery or for shoulder reconstruction in the case of arthritis.
Shoulder1: You serve as chief investigator for a study examining open versus arthroscopic surgery for instable shoulders. What are the pros and cons of each? What have you discovered so far? What is the cost difference between the two?
Dr. Warner: All surgeons should perform the procedure with which they have the greatest experience. Open surgical stabilization, Bankart repair, was pioneered at the Massachusetts General Hospital by Dr. Carter Rowe. He and his colleague, Bertram Zarins, have shown this to be a very reliable and effective method to treat shoulder instability. However, for the last 10 years, I have been using arthroscopic repair methods almost exclusively to treat shoulder instability when it occurs after a trauma. These methods allow for a smaller incision, less pain, faster repair, and the possibility for the patient to go home after a local nerve block rather than general anesthesia. My own prospective study over seven years showed that the outcome for open or arthroscopic surgery was the same. However, a recent study we performed at the Massachusetts General Hospital showed it to be faster and cheaper than open surgery for instability.
Shoulder1: You have also headed up a similar study on rotator cuff repair—all-arthroscopic versus open-cuff repair. Which seems to work best for this specific injury? How does a surgeon decide between the two when considering a rotator cuff repair?
Dr. Warner:This is a controversial topic and it remains unclear, based on lack of scientific evidence, which method is better. In order to answer this question, we have designed several outcome studies to determine if one is better than the other based on patient experience or final objective outcome. At this time, arthroscopic repair is more surgically demanding and biomechanically less optimal than open repair; however, patient pain appears to be less.
Shoulder1: How has arthroscopy improved since you started your career as an orthopedic surgeon?
Dr. Warner:Arthroscopy has improved in leaps and bounds. Cameras are better. Motorized shavers are better, and instruments for surgical repair are designed not only better but also in a way which makes it easier for any surgeon to do arthroscopic repairs. At the new millennium, it can now be said that arthroscopic surgery is commonplace and the standard of care. Not long ago, however, these methods were considered experimental and the common method was open repair, which resulted in a longer hospital stay, more pain, and less-attractive incisions. Now, shoulder instability and rotator cuff tears are easily and quickly repaired under local anesthesia, using techniques that leave small scars and cause less pain.
Shoulder1: What has been the most interesting shoulder-related project or surgery you have ever worked on?
Dr. Warner: I have been involved in many projects. These have included biomechanical analysis of normal and abnormal shoulder function as a basis for surgical repairs. In addition, I have been fascinated by the development of outpatient arthroscopic techniques that allow for surgery to be performed under local anesthesia and the patient to go home the same day. Probably the most interesting aspect of shoulder surgery is reconstruction of the arthritic shoulder using an artificial joint. For the past decade this method of treatment for arthritis has grown from therapeutic nihilism into a method that now regularly permits people to return to tennis, golf and swimming with good shoulder motion and no pain. I have been involved with analysis of these methods of treatment and outcome of joint replacement for arthritis.
Shoulder1: There have been many great gains in orthopedics in the last few years. How do you see further research benefiting the shoulder joint?
Dr. Warner:The future of orthopedics will not only be based on advancements in biomechanics and technology like arthroscopy, but will largely be based on advances at a molecular level. Genetic engineering that allows modification of soft tissues and cartilage as well as bone will completely change the way we manage and perceive orthopedic disease.
Visit Dr. Warner's web site at http://www.bostonshoulder.com.