Shoulder Replacement Surgery with Dr. Frankle and Dr. Mighell

My name is Mark Frankle. I’m an orthopedic surgeon. I practice at the Florida Orthopaedic Institute. My education began at Grinnell College in Iowa as an undergrad doing pre-medical studies. I finished that in three years and started medical school.
As my fourth year of college, my first year medical school, I did a year of research in medical school and then I started my orthopedic residency at the University of South Florida here in Tampa.
And then I did adult reconstructive fellowship at the Mayo Clinic and I also did a year of research in the Orthopedic Institute in Davos, Switzerland. And then I started my practice that specializes in the treatment of shoulder and elbow problems in adults in 1992.
I’ve been doing shoulder replacement since 1992 and we’ve done close to six thousand shoulder replacements and those would be considered either total shoulders or reverse total shoulders or some other form of a shoulder replacement. My most recent accomplishment is that I have been elected by the American children of both society to be the president of that society and that’s the society of the that’s children elbow surgeons in the world. It currently has a thousand members. And. It starts out that I’m the vice president this year. Next year I’ll be the president elect, and in 2021 I’ll be the president. And as the president I preside over the annual meeting which will be in Tampa because that’s my hometown and we’ll have over a thousand shoulder surgeons from around the world coming to that meeting to discuss the newest treatments outcomes of children elbow surgery and it will be quite exciting.
So that’s my most recent accomplishment and I’m really quite proud of other accomplishments as I’ve been training fellows to be shoulder and elbow surgeons being my first fellow around 1996. And I think since that time has trained about 50 shoulder surgeons we now take three fellows a year and we get about 30 applicants a year so again fairly competitive and of those people we we trained them they spend a year with us and that’s another great accomplishment because many of them have gone out on their own right and become really quite well-known and successful shoulder mobile surgeons.
When we look at outcomes of patients after shoulder replacing we never give people the normal shoulder after we make them better. And part of the research that we’ve done for the last three years is trying to figure out an accurate way to represent outcomes that are something that we can measure in a way that clearly defines the effectiveness and maybe the limitations of the procedure.
So we’ve come up with various different ways and again people are uniformly better.
They have less pain they have more mobility many people can go back and do many of the activities that they were unable to golf tennis working out many activities but some of it is dependent upon the patient’s own motivation and their skillset.
But it’s you know today I saw a guy who I replaced both of his shoulders. He’s An avid workout guy. You saw this guy you would never believe this guy’s had a shoulder replaced. I mean he’s he’s he’s really muscular and he’s in the 60s and he you know he couldn’t do that before.
So that’s an example. Just today I saw and it’s common and that’s what the goal of a joint replacement is to improve patients quality of life so you can be active and you can achieve some of the activities that you’re arthritic condition limits the difference between an anatomic shoulder replacement and a reversal replacing again.
The idea is when the muscles are good and the joint has worn out much like you might wear out the tire treads in your car symmetrically and replacing that joint with surfaces that match up that’s when you would use an anatomical replacement in cases where again your treads might be riding off way to one side.
So there asymmetrically one that’s whenever a reverse shoulder would be considered and the parts are very similar looking except where the ball is normally that’s when you would do an anatomic ball and reverse and you have a socket there, and the socket side with an anatomical replacement, replace the socket with the socket whereas reverse you replace the socket with the ball. Our normal shoulders are amazing in terms of their own ability to provide motion. That’s the hallmark of shoulder joints as opposed to hips and knees. They have an extensive amount of motion allowing us to throw, allowing us to reach behind our back back down in her head. Do other activities such as strength that. Put these over our head and it’s that combination of mobility stability and strength that separates the shoulder joint from all the other joints in the body and in order to have a to replace his shoulder. It’s important to understand well what is the mechanical problem that the patient is trying to resolve.
And the mechanical problem often is the source of the complaint. So patients don’t come to me and say I have an arthritic shoulder they say my shoulders painful and I no longer can reach the back of my head or I no longer can can use it my arm to paint the house or I can’t sleep on my shoulder because it wakes me up at night.
And then when you examine someone with arthritic joint you find their motion is restricted because they don’t have a smooth articulation.
So in an arthritic shoulder the ball is now rough in the socket is right. And if we’re going to do a quote anatomical replacement we’re going to replace that Ruffin ball with a new smooth ball and we’re going to reshape the socket with a smooth socket. So the mechanical problem of osteoarthritis with a surface is rough has now been treated with smooth surfaces but they’re in the same position and the same shape as the normal shoulder joint before you had surgery in a reverse replacement.
We don’t respect that same shape. So where the ball was initially we now place it with the socket and where the socket is we replaced that with the ball.
And the idea behind is that it is asymmetrically wearing off the shoulder because there is muscular imbalance. If you don’t address that and you replace that with a ball and a socket like a normal anatomical shoulder you’ll still have that asymmetric where it’s sort of like the tire in your car if you don’t balance those tires you’re going to wear out asymmetrically and you really won’t be further down. So finding a solution that you might call so that’s the real difference. And that’s why they could look slightly different. I’m often asked about how likely is this operation to help me and how long. So again the research show we’ve been doing here at Florida Orthopaedic Institute in conjunction with the Florida Orthopaedic Education Foundation has really tried to answer it. So if the six thousand shoulder replacements I’ve done over the 30 years I’ve practiced here in Tampa we’d have several thousand patients that we have data that we have data before their surgery data afterwards and we expect their patients to come back every year.
Now many patients don’t but we have number of patients to do. And so from that data we’ve published our experience in in peer reviewed journals.
So when we publish something in a peer reviewed journal that means it’s the highly highest level of scrutiny it’s sent out the colleagues around the world who are experts in this field matter and they look at the scientific method of how we did our studies did we use good scientific method.
Our results were reproducible and from those studies we can say that if you have a reverse shoulder replacement the likelihood of you having 10 years of having a shoulder that works well with little pain is about 92 percent. And that was done on patients that were at the earliest generation. So we think that our results are probably as good as that. Currently we don’t know past 10 years because again I started doing these operations in 97.
There have been many different iterations of that. It was only FDA approved in 2004. So we don’t have a lot of patients that have longer than that. But you know that’s part of why it’s an ongoing research.
But that gives an idea to someone who has a disability that they can look forward to an improvement that’s likely to be fairly durable. Well whether it lasts in the life. I don’t know but that’s a pretty good idea about what they can expect in terms of improvement of comfort and function on their shoulder in which anatomical replacement is probably about the same. We haven’t looked so much at that although we’re currently looking at that now and it looks similar. I’ve had both my shoulders replaced my left shoulder is replaced about 15 years ago on my right shoulder was about a year ago and a half ago as a result my shoulder pain is diminished. I can do activities now before I can tie my mats for surgery. I can do overhead exercising I can see comfortable on my shoulders. So overall my overall health and well-being is substantially improved.
Now before it be hard to put on a coat be hard to see comfortable going to put something up in the overhead bin would be a struggle. It would be difficult to accomplish the things I wanted to in a day because my shoulder pain or restrictions for me shoulder replacement surgery is generally very well tolerated.
For example after my right shoulder replacement I didn’t take any pain there’s nothing. It is remarkable. It’s very well. tolerate. So if you do a rotator cuff surgery you make small incision you do as an outpatient.
So it really lets people you know sorta bait and switch type thing. And you do a show replacing you’re in the hospital generally for a day or so but it’s a bigger operation but it is very well. Most people after show replacement they really don’t need to do a lot of therapy. We don’t send the physical therapy. We have them do exercise. The majority of people can do on their own. Once you make the joint so it moves smoothly. People can now do their motion they don’t need a lot of coaching or stretching those sorts.
So there are there. It is very difficult to tell someone exactly what they can do but you can say based upon the work that we’ve done here it’s very likely you’ll notice a reduction in your shoulder pain and you’ll notice there’s many things you can do now that you couldn’t do before. And that’s fairly thorough.
So we don’t impose restrictions on my left shoulder replacement was done by Dr. Cofield at the Mayo Clinic 50 years ago. And he was the person I studied under. That was my fellowship director when I was getting my education.
And then last year a year and a half ago Dr. Mighell at the Florida Orthopaedic Institute that did my right shoulder and he was one of my fellows 20 years ago.
My name’s Mark Mighell and I’m a shoulder an elbow specialist at Florida Orthopaedic Institute in Tampa. I came here almost 20 years ago and my educational background started at the University of Virginia as a University of Virginia Cavalier. You can imagine I’m very excited right now because we’re got NCAA champions but besides that I studied chemistry and languages I actually speak six languages including Russian which is my mother’s first time as a child. When I finished university Virginia I went to the University of Maryland School of Medicine in Baltimore. And there I started studying medicine.
I became fascinated with anatomy particularly the anatomy so while a student I focused on doing research projects anatomical dissections of the shoulder elbow and hand I had the pleasure of rotating on a service called shoulder and elbow where in fact I saw shoulder replacements.
I also saw arthroscopic procedures done for the first time. I was fascinated with the shoulder and I thought to myself that for me a career in shoulder and other surgery would be more rewarding. I also really like the patients. Many of the patients who came into the shoulder at our clinic were golfers, tennis players, or like to work out.
In this capacity I was able to meet many wonderful individuals who convinced me that shoulder surgery was my call. Having decided that I did the fellowship and shoulder and elbow reconstruction in the Tampa Bay area in 1997/1998. I did perform procedures as a resident.
However once I became a shoulder and elbow specialist from 1998 to 2018. It’s been over 20 years so I’ve had a wealth of experience and in fact at this point. I’ve done over 2000 primary total shoulders and close to 500 division art classes for 2500 surgeries.
That has to do with shoulder art plus neither passions are gossipy and for me arthroscopy is a three dimensional kind of challenge where you can fix a rotator cuff and you can do wonderful things to improve stability of shoulders and then in that field I’ve done over 2000 arthroscopies to repair rotator cuffs and cracked shoulders that are unsafe.
In addition I have been working tirelessly to work in terms of producing manuscripts or literature regarding children of all problems and this also has allowed me to join a very prestigious group of shoulder and elbow surgeons called the American Shoulder and Elbow Society. This is a group of like minded individuals who enjoy improving research and education and we read on an annual basis and every year we needed a different location. I’ve been a member of the American Shoulder and Elbow Society since 2005. In addition that I really love my community has been involved in my church policy at Presbyterian. I love to local high school and I’ve been a team physician at Plant high school for over 10 years. I’ve had an opportunity to see many young athletes and treat them when they get injured and this has been very exciting for me because I really enjoy Friday night football is important in terms of other awards that I’ve received. I have been nominated to be a Boards Examiner meaning that when you become an orthopedic surgeon and you say you are a board certified someone examined you.
I’m one of the individuals that they have selected to examine young orthopedic surgeons to determine whether they can in fact become board certified. I’ve been really involved in children elbow research and in academics educating both residents and fellows.
I’ve been part of an accredited fellowship program since 2002. We’ve trained many fellows who’ve gone across the United States to continue doing shoulder and elbow surgery. In terms of the peers my peers make me even nominate me as best doctor in America for over, 10 years since 2007, and I take that as a real tribute because these are other physicians other orthopedic surgeons in the area who feel that if they have a patient with a real problem they’d be happy to send their patient to me.
One of the things I really wanted to talk to people about is arthritis itself so arthritis is actually inflammation of the joint that occurs as people get older and most arthritis is due to aging changes or natural history but sometimes it’s due to an accident or trauma to the shoulder joint. It can be due to prior surgical procedures and what’s arthritis starts to set in. What happens is the joint becomes inflamed it is irritating so you get pain and when the joint is inflamed the fluid in the joint actually changes.
So people with arthritis instead of having a thick libricant from your shoulder are getting more watery fluid. And as time goes on the beautiful cartilage cushion inside the joint that takes the shock when you’re doing activities starts to wear away.
Bits of cartilage can flake off. Sometimes the first presented complaint is just tenderness or swelling and usually this occurs in the morning. Oftentimes people wake up on their shoulder is stiff and sore and they’re confused like they did too much. But in fact what happens is as they start using it again it feels a little bit better.
So that tells us that some gentle exercise is always good for patients who have arthritis. So I’ve found that when people come in I tell them you need to hydrate, keep your weight down. You need to continue to be active. Arthritis isn’t a disease that makes you slow down. You should continue to do activities you enjoy by not doing activities it’s going to affect your overall health and other activities you do. One of the things that are that I always prescribe my patients when they first come in is glucosamine hydratio sulfate which helps to stabilize a cartilage and I think it’s nice is that a lot of people are into some of the more natural preparation so some patients will gravitate towards tumeric and sometimes you can use tumeric with pepper which you can get at your local pharmacy or at the grocery store or other things that are good are perhaps an over-the-counter anti inflammatory.
So for mild arthritis pain, Motrin or ibuprofen is one of the top selling drugs in America.
That’s because so many Americans have arthritis.
So taking that is not bad but if you take it long term you have to think about the other things that go along with taking the anti-inflammatory. You can have blood pressure elevation. It can affect your kidneys.
You can get ulcers so you really should consult with a doctor before you take long term use of anti-inflammatories. This is for early arthritis.
Sometimes patients come in and they have no idea they have a place and you get an x ray. It looks awful. And they say well I didn’t have arthritis until I fell down.
But in fact that was the final defining moment for their arthritis. That kind of straw that broke the camel’s back that led them into the doctor’s office.
So once you have arthritis patients are often confused because they don’t feel that old or they don’t want to be that old and they’re looking for some answers retreat at present. Sometimes a cortisone shot can reduce inflammation and no one can help them get engaged with a physical therapist to work with your lives.
If that doesn’t work then sometimes we can start talking about surgical procedures and a lot of people come to me and they go either I don’t understand what a shoulder replacement is and what’s the difference between a reverse shoulder. My neighbor had an irregular or traditional shoulder. And in general to do a traditional shoulder you have to have a very very healthy rotator cuff.
You can’t have a rotator cuff tear or a on the rotator cuff. And generally those patients are a little bit more active and younger when I do the total shoulder with. So before we ever do a shoulder replacement we oftentimes will get advanced imaging and by that I mean either an MRI scan which people are familiar with or a cat scan or C.T. scan. The MRIs Magnetic fields and C.T. scans are more radiation so you do get exposed to some radiation.
But now we can make three dimensional reconstructions and kind of reconstruct the disease joint so we can plan out a surgical procedure. I generally tell people that until their pain is horrible or their bad days outnumber the good days. It’s probably better not to have the operation. Do you want to maximize your own body and maintain your own body. You actually haven’t had to. So for the other type of shoulder replacement the reverse shoulder.
This is a device that was developed for patients who have a deficient rotator cuff. So if you have a rotator cuff tear prior rotator cuff surgery for your joint is it balanced the reverse shoulder kind of acts like an artificial rotator cuff and a shoulder replacement. It has more constraint and it allows you to regain function of your arm.
So there are quite different operations in the sense that one needs the rotator cuff to be highly efficient and the other.
It’s nice that you’re at the top but you don’t need. So these operations consult with either your orthopedic surgeon or myself or another doctor we can help to explain this to you in greater detail.
Now what these materials are a lot of people don’t really understand what a jaw replacement but actually you’re just taking off a little bit of the actual joint surface. But even though the implants can move larger the amount of bone removed is no bigger than a bubble that it is a tiny little bit of bone you take out and you replace that pitted corroded kind of worn out bone with a beautiful cobalt chrome ball.
These days some patients even have allergies to nickel. So we even have all titanium shoulders that are kind of innovated that have come out and help us to deal with metal allergies.
So once you made the decision to have a shoulder replacement it is something that sometimes can be scary because if you haven’t had a surgery you could be nervous. One thing I can tell you is that when you have a shoulder replacement the actual operations that you go to someone who does over 50 years probably takes less than an hour and you’re only going to spend one night in the hospital if you’re very healthy. You potentially could go home the same day. There’s very little blood loss. It’s rare to have a blood transfusion and the success rate is over 95 percent. So it’s a very very good operation and durable. So no shoulder replacements will ask for 50 years. And we have now had data that shows that the reversal that can even last 20 years. So that is a long time for your shoulder replacement. And I always tell people the risk of anaesthesia. If you don’t have a severe heart the lung conditions it’s the same risk as flying to LA. So it is not a very dangerous operation.
I was introduced to a concept controversial replacement in the early 90s by a friend of mine in France who told me that he had great success with some version of that. But he didn’t really understand how it worked. So in 1997 I did my first reverse shoulder replacement.
And this is well before anyone in the United States considered doing it. And we had some problems on our early designs but we continued because we were encouraged by some of the outcomes that we were seeing and these outcomes now are the standard. They are unbelievable. In the shoulder there is a great deal of mobility and the mobility as it occurs by a joint that does not have a lot of constraint. If you look at the shoulder it looks like a big ball on a golf team. And so the way the shoulder stays stable normally is the muscles around the shoulder that keep it stable. But as we get older or some traumatic cases or some degenerative cases your rotator cuff muscles and tendons may become affected.
And now you develop some sort of muscular imbalance and this imbalance can be quite severe and incapacitating the patients where they can’t use their arm to eat they can’t use it to bathe. They can’t use it for sporting activities. They have severe pain that limits their ability to rest comfortably.
And so it is a significant problem that impedes one’s life in terms of the quality of their day to day existence. So a reverse replacement provides stability to the joint and it does so again by reversing the articulation. So the things that we’ve done in our research lab that have led to these breakthroughs have been trying to identify the ideal patient. The ideal prosthetic design what patients are not many so well suited for it. And that has been the last 20 years of our work. And again it has been really quite gratifying to see that we’ve made major contributions that our work has been honored throughout the world. I’ve been very involved in innovation. I’ve been very fortunate to have a group a manufacturing company and a group of researchers to help me really improve reversal. Is something I pioneered the United States and I continue to try to improve that surgery by finding the right patient by having the right implant.
So one of the things that has been recent as we realize at some point that we wanted to have a variety of sizes available so about five years ago is clear that the socket side which is on the ball side of the normal shoulder we only have one side. And that was a problem. We really needed to have a smaller shell or smaller socket. So in the last year we’ve come out with a smaller socket and it really has allowed us to treat people far better especially smaller stature people women that are generally in that category. So that’s been another innovation and the innovation process. You know we’re continually to strive to make this better to the future of shoulder replacement is it’s not going to be I don’t imagine one big deal reverse shoulder replacement was a big deal that was a big shift. These are not all incremental shifts we’re finding we can do the surgery with less pain where do it we’re finding we can do the surgery quicker and easier.
We’re finding patient selection that bit better and we can allow patients go back to these activity levels which before we would be reticent to do so.
Those are the current advancements I think for the patients who are trying to consider whether or not they should have surgery. I just say look if it gets to the point where I notice this every day in your life and every day in your life you’d like this really. This is really impacting. And if you start thinking gosh if I could have anything for Christmas what I’d really like is a good shoulder.
Those are pretty good hints that maybe you should think about getting treatment because you’re likely to find it really helps you most of the time and we’re trying to decide something.
It’s often fear that is our biggest impediment and it’s interesting when you look at research on psychology people will do more to avoid losing a dollar than they will make the same dollars just one dollar. So we’re very fearful and sometimes we feel that we have to accept things because we’re like oh my life’s not that bad. My shoulder hurts a little bit but it’s not that bad. And it is truly not that bad. Denial of your symptoms is the visible coping strategy to no longer work. So at 2:00 in the morning you’re waking up and your shoulders hurting you.
Just remember that there is a treatment available for you. That’s safe. It’s effective and it’s very likely to help.