MO:
How did you make a name for yourself in shoulder surgery?
JCP:
That’s a good question. I think, like many things, by accident.
When I finished my training, I was a surgeon with an interest in joint
reconstruction, with a particular interest in rheumatoid arthritis.
One of my senior colleagues had been in Montreal, and had been taught
to do shoulder replacement. He came back, and brought shoulder replacement
with him. He was dealing with rheumatoid patients, and I started to
help him with one or two. He then went to work permanently in Canada,
and the demand remained. I had done other shoulder surgery – stabilizations
and shoulder trauma – and I started doing shoulder replacement.
MO:
When was that?
JCP:
In the early 80s. I had an interest at that time in the hip and knee
– knee ligament reconstruction. But because I was operating on
shoulders, my colleagues would ask me to have a look at their patients
with shoulder problems. So I started looking at shoulders, and realized
that I really didn’t know a lot. So I tried to read about shoulders,
but in the early 80s, there was very little available, so one had to
think a lot about it, and I worked a lot of things out for myself, and
had a look at the anatomy. And then in, I think, about 1984 I went along
to my first shoulder meeting. I remember that very clearly, because
when experienced shoulder surgeons, people like Neer, got up and said
things I felt very reassured that I agreed with a lot of what was said,
but I also felt that some things that they said I didn’t agree
with, on the basis of my experience. That was a great stimulus to me
to do more. I was able to learn from my patients, to ask questions to
which, perhaps, the answers weren’t there. I think I have been
very privileged to be able to get into an area of surgery that was actually
beginning to develop. I suppose I may be known because I started in
shoulders before it was fashionable, and I think it’s now become
very fashionable.
MO:
When you started in shoulders, were you the only shoulder surgeon in
Glasgow?
JCP:
Well, surprisingly to me, I think I was one of the very few people in
Scotland who was doing much in the way of shoulder surgery, especially
shoulder replacement. When people heard about it, colleagues began to
send me patients they were having difficulties with. Since the late
80s, I have run a Problem Shoulder clinic, and I only accept referrals
to that from other orthopaedic surgeons. I do get patients from a long
way. It is a very useful clinic for teaching and discussion. But now
Scotland has many, many more people who are interested in shoulders.
MO:
Why did you have so many rheumatoid patients?
JCP:
Largely because there is a lot of rheumatoid arthritis in this part
of the world; and perhaps more specifically because the rheumatology
services were organized in such a way that patients were brought into
Glasgow from many different parts of Scotland. That meant that if they
needed surgery, it was more likely that they would be referred to a
Glasgow surgeon. So I started my experience with arthroplasty mainly
with rheumatoid arthritis. But it also became clear that rheumatoid
patients had problems in their shoulders for which arthroplasty was
inappropriate. They had problems with the acromioclavicular joint, and
the subacromial region. And so I started to ask questions about this,
and did studies trying to analyze where this pain was coming from.
MO:
How did you do these studies?
JCP:
They started by accident. I did a sabbatical attachment in Lund, in
Sweden; and I had a rheumatoid patient who was complaining of shoulder
pain. I examined the patient: he had a painful arc of motion. But then
I saw his radiographs: his glenohumeral joint was damaged, and one would
have thought he needed a shoulder replacement. But clinically his range
of movement was good. So I injected his subacromial region with local
anaesthetic, and he did well. Eventually we went on and did a decompression
of the rotator cuff. But the intriguing thing was that the glenohumeral
joint was also damaged. As a result of that, I looked at a number of
patients, and used local anaesthetic injections into the subacromial
region, the acromioclavicular joint, the glenohumeral joint, to map
out where their pain was coming from. That was very interesting, because
if a rheumatoid patient had 30 degrees or so of external rotation, and
retained the spherical appearance of the humeral head on an x-ray, then
it was very likely that the pain was coming from the subacromial region
and/or the acromioclavicular joint. And that sort of patient didn’t
need an arthroplasty.
MO:
How did the Elbow and Shoulder Society come into being?
JCP:
It was at the International Congress of Shoulder Surgery in 1986, in
Japan. The British surgeons who were there got together and said, well,
we really should have a society in the UK. They got in touch with me,
and I was certainly interested. I was able to organize a meeting in
March 1987, in Glasgow – and that’s when we started the British
Elbow and Shoulder Society. I think we had 24 people at that meeting.
That Society has continued, and it has got stronger. It has reached
a stage in its development when it has a role in determining educational
standards, and interacting with the Government on standards of practice;
to a certain extent also on standards of implant manufacture. Its membership
is open – it is open to orthopaedic surgeons, physiotherapists,
rheumatologists, and engineers. We have an annual meeting, which is
very well attended.
MO:
Who were the leading British surgeons at that inaugural meeting?
JCP:
At that time, we were looking at Ian Bayley, Mike Watson, Steven Copeland,
Angus Wallace. We had Brian Reeves, who had done a lot of work on shoulders
in much earlier times, in Leeds. He was one of the first people to introduce
the reversed-ball type of shoulder prosthesis. His prosthesis really
did not take off. But he did this work, he was into the bioengineering
side; and I think the value of his work sometimes is not realized. Christopher
Constant was also at that meeting. The other person who was there, of
course, was Willy Souter who had a major interest in the rheumatoid
elbow.
MO:
What were your functions in the Society?
JCP:
When it started, I became the Secretary, and Willy Souter was the first
President. After five years, I left the Committee, and then rejoined
it a few years later, as Vice-President. And then ultimately I became
President, in 1996.
It was again in 1987 that the inaugural meeting of the European Shoulder
and Elbow Society was held, in Paris. I have been involved with that
Society from fairly early on, because initially I helped Gilles Walch
to edit the Bulletin, the bilingual information sheet. I became a national
delegate. I think the European Society has a very important role to
play. It’s changed a lot since it started. Initially, its constitution
had a structure that, in the UK, we would have thought of being rather
old-fashioned. But I think that has since then been adjusted and balanced.
When the Journal of Shoulder and Elbow Surgery began, I was the co-editor
in Europe, with Michel Mansat.
MO:
When did you join the American Shoulder and Elbow Surgeons Society?
JCP:
I was invited to become a member of the American Society about four
years ago. It is a small group, but the communication is very good.
The Americans were really responsible for setting up the JSES. There
had been a lot of talk in the European Society about establishing a
journal, but the real moves came when the American shoulder and elbow
surgeons took a step and spoke to Mosby. And they involved the other
shoulder societies around the world, and made it truly international.
MO:
There are not many journals that manage to bring specialists from all
over the globe together...
JCP:
It’s perhaps because shoulder surgery really developed rapidly
during the 80s, when communication was better. It developed almost simultaneously
in Europe and the States. And everyone was looking for a journal at
the same time.
MO:
Is there an inherent difference between the European approach to the
shoulder, and the American way?
JCP:
I think it’s often thought that there is a competition between
the two, a conflict, perhaps. But the really encouraging thing for me
is that you go to the European Society meetings, and there are a lot
of North American surgeons there now. Although the approach is different,
largely because of the medical cultures we work from, the thought process
and the ideas are not in conflict.
MO:
Do you have contacts with the French shoulder surgeons?
JCP:
My main links have been with Michel Mansat, at several levels. First
of all, through the European Society; and then through his interest
in arthroplasty. We were both involved in the development of the 3M
modular prosthesis, at about the same time. We came to know each other
through meetings over that. Also, we shared (and still share) an interest
in rugby. And shortly afterwards, the JSES was established, and I was
asked to be co-editor for Europe with Michel Mansat, and that increased
the contact between us. I have been to Toulouse a number of times, and
I have had one of Michel’s senior residents over. Of course, through
the Society, I was also corresponding with Gilles Walch.
MO:
Where did you train?
JCP:
I trained in Medicine in Edinburgh, although I went there to study Psychology,
and my exposure to the biological sciences during my first year made
me decide to do medicine. One of my first post-qualification posts was
at a small hospital in Perthshire, and that’s where Smillie did
his meniscectomy work. That was my first orthopaedic post. Then I returned
to Edinburgh, and started by basic surgical training. I did my Orthopaedics
in Edinburgh, working in the Princess Margaret Rose Hospital and the
Royal Infirmary, with Professor James and a number of other surgeons.
But then I had to take my Fellowship of the College of Surgeons, and
to do that I needed general surgical experience. I failed to get a post
in Edinburgh, but went to Liverpool for two years. I had been asked
to let Edinburgh know when I had got my general surgical training completed,
but there were no posts available. But I was told that there was a post
coming up in Glasgow, and it would be a good idea for me to apply. So
I came to Glasgow in 1977, with the initial intention of going back
to Edinburgh, and I am still in Glasgow.
MO:
Is there a great deal of difference between Glasgow and Edinburgh?
JCP:
There is a very strong and long-established rivalry between these two
cities. The people of Edinburgh are said to be more reserved and perhaps
a little less welcoming than the people in Glasgow. There is a little
story. It is said that if you arrive in Glasgow in the late afternoon
at somebody’s house, they will ask you whether you want to have
your afternoon tea. But if you go to a house in Edinburgh at that time,
they will say “you will have had your tea then”. There is
a difference, too, climatically. Glasgow is very wet, being in the west.
Indeed, before I came to Glasgow, I had not owned a raincoat for a number
of years because Edinburgh, being on the east coast, is much drier.
It is colder, but drier. There are only about 50 miles between Glasgow
and Edinburgh, but the two cities are very different. One of the longest
50 miles in the country, I would say.
MO:
Were you born in Edinburgh?
JCP:
I was born in Liverpool, and grew up there.
MO:
You grew up in Liverpool in the 60s – how come you didn’t
found a rock ‘n’ roll group?
JCP:
I wasn’t good enough. I was into folk music in the 60s. But I was
in Liverpool when the Beatles made it, and the Cavern was active. It
was exciting; it was revolutionary.
MO:
Why did you leave Liverpool?
JCP:
There is a degree of Celtic influence in my family, and I very much
wanted to come up to Scotland to study. As I already said, I was very
interested in Psychology, but then changed to Medicine. Currently, in
the UK, that is a five-year course. When I went to medical school, it
was six years. And then you qualify in Medicine, and you have to do
one year, when you are provisionally registered. That post is called
a Junior House Officer post in England; in Scotland, it is called a
Resident’s post. And that year includes six months in a surgical
unit and six months in a medical unit. At the end of that year, you
are fully registered. When they have finished that year, most people
then will go into a Senior House Officer post, which goes on for two
years. In the current system, that will form part of what is known as
Basic Surgical Training post. There is no examination, it is open to
those who want to become surgeons. Towards the end of that two years,
you will sit an examination at the Royal College of Surgeons.
That will give you a degree which is now known as the MRCS – the
Master of the Royal College of Surgeons. And then the idea is that you
would move on into what is known as Higher Surgical Training, which,
in Orthopaedics, lasts six years. But, of course, there are a fixed
number of posts, and the demand for these posts is high. So there is
this gap between Basic Surgical Training and Higher Surgical Training.
There are a number of intermediate posts, again called Senior House
Officer posts, which people can get into, or they can do a research
job and publish papers, just to improve their chances of getting into
higher surgical training. The Higher Surgical Training is six years.
Trainees will move round from one post to another, probably every six
months, and it will include all aspects of orthopaedic surgery. After
you have completed four years, you will be eligible to take the Fellowship
in Orthopaedics and Trauma. This is rather a major examination; and
you must pass this in order to become a specialist in Orthopaedics.
This examination involves a written paper, clinical examination, and
then four oral examinations. During the two further years of Higher
Surgical Training, our trainees will try to organize to work abroad
for a year, and will begin to develop a specialist interest. And then,
at the end of the six years, you are eligible to apply for a Consultant
job.
MO:
What did you decide to do at the end of your training?
JCP:
One of my research interests was, and still is, in the area of bioengineering.
I won a scholarship to go round North America visiting centres that,
at that time, were very much working with gait analysis. I also spent
some time at the Mayo Clinic. I had been making arrangements to go and
work in the Bioengineering laboratory there but financial considerations
prevented that in the end, and that’s why I subsequently arranged
to go the University of Lund, where they have a very, very strong rheumatoid
surgery section. As a result, I have kept in touch with the Swedish
centres.
MO:
Looking back to the 80s and 90s, and the ideas proposed by Neer, in
what way have your concepts of shoulder pathology changed?
JCP:
I have the greatest respect for Dr. Neer. I was very fortunate in 1986
to meet Dr. Neer, when I was on an ABC Travelling Fellowship. I think
he has done so much for shoulder surgery, but there are a number of
his views that I do not agree with. I have never been able to accept
the Neer grades of impingement. Why does the osteophyte form in the
first place? I am a firm believer that the original pathology is in
the rotator cuff, and that the impingement is secondary. My interest
in the loose shoulder also makes me feel that there is a dynamic aspect
of shoulder control, and the interaction between pain and muscular control
of the shoulder, which also contributes to this impingement picture.
To that extent, I am not the only one to disagree with Dr. Neer on that.
MO:
What do you see as your main contribution to shoulder surgery?
JCP:
I hope I have made some contribution to a better understanding of the
rheumatoid shoulder. I still feel a long, long way from understanding
it. I have several ongoing projects. I need the help of molecular biologists
now, for some of the work we are doing. It’s like many other things
– when you go into a subject in depth, it becomes more and more
fascinating. I am excited by what we found with the rheumatoid shoulder,
the different patterns of disease; the way the different patterns correlate
with clinical findings, and the possible implications for surgery.
MO:
When it comes to shoulder replacement in rheumatoid patients, would
you consider total shoulder replacement or a hemiarthroplasty?
JCP:
I am going to give you another complex answer. When I started doing
shoulder replacement, it was routine to open the shoulder, remove the
head, put in a glenoid component, and then fit in whatever humeral component
you could. It meant that the shoulders were often very tight by the
end of the procedure. Then I became aware that soft-tissue tension was
as important in the shoulder as it was in the knee. So I started to
try to approach the rheumatoid shoulder in a different way. I would
start by doing soft-tissue release. Then I had to decide which size
of prosthesis to put in to give the best result. At the end of the 80s,
there had been two studies done looking at the range of motion you need
for activities of daily living. So I decided that what I wanted to do
was to give the patient at least 30 degrees of external rotation, 90
degrees of internal rotation, and 90 degrees of abduction at the end
of the procedure. And I found that once I had created a space with the
soft-tissue release, there were some patients in whom there was not
enough room for a glenoid. So they got a hemiarthroplasty. But Norbert
Gschwend’s paper on the outcome of hemiarthroplasty versus total
arthroplasty, which showed a qualitative difference in favour of total
arthroplasty. So I adopted the point of view that I wanted to put in
a total replacement when I could. When we did a medium-term follow-up
of the 3M modular shoulder, which allowed better soft-tissue tension,
there was virtually no difference between the results. In theory, I
still think I am doing the right thing, but in terms of range of motion,
and patient satisfaction, there doesn’t appear to be a difference.
That’s why my answer is complex. There is perhaps another element
that I should mention: if we are talking about the rheumatoid shoulder,
the pattern of disease appears to have an effect. If you do a hemiarthroplasty
in a patient who has an erosive pattern of disease, then you are more
likely to get a progressive erosion of the glenoid six years on, than
with any of the other patterns. Of course, those patients are also more
likely to have ruptured rotator cuffs. So there is an influence of the
pattern of disease; and that may also influence how I treat the patients.
But it’s an incomplete knowledge, so it can’t yet be used
as a definitive guide to treatment.
MO:
What about bipolar prostheses for rheumatoid patients?
JCP:
I have never used one. One of my colleagues uses them very regularly,
and has reported very good results. Of course, if you believe that most
rheumatoid patients have a non-functional rotator cuff, there is perhaps
some logic in it. I am sure there is a place for them, but one of the
things that sometimes happens with these devices is that they are used
for everything.
MO:
So what do you do when there is no cuff?
JCP:
A variety of things. In patients in their seventies, eighties, I use
a reversed arthroplasty, a constrained device, a Grammont. However,
I have only done three over the last 18 months. It works very well,
initially. But as with any constrained arthroplasty, the glenoid fixation
will fail. And that is why I think it should only be considered in patients
in their late seventies and eighties, where the demand is low, and the
life expectancy is not that great.
A standard hemiarthroplasty may also be considered if the subscapularis
is absent. In that case, I will transfer the upper two-thirds of pectoralis
major beneath the coracoid muscles and into the lesser tuberosity, and
maybe onto the front of the greater tuberosity. I have found that to
be a very effective procedure. Obviously, that demands that there is
some infraspinatus there. The big problem is when there is no infraspinatus
and no subscapularis. I have very little experience of latissimus dorsi
transfer. I have tried one or two teres major transfers, in association
with a prosthesis, to try to balance that prosthesis. Beyond that, I
have, in fact, used Benjamin double osteotomy, where, essentially, you
are making an osteotomy through the surgical neck, and about one centimetre
behind the glenoid, in each case leaving the posterior cortex intact.
In rheumatoid, I just do the humeral side. I think it’s a decompression
of the venous hypertension round the joint, and it’s purely for
pain relief. It doesn’t work in all the patients, but certainly
it helped some of my patients, and it is conservative surgery. One could
even go in and just make the drill holes.
MO: But why do a prosthesis?
JCP:
Some people make the mistake of confusing a cuff-deficient shoulder,
a bald-headed shoulder, with cuff arthropathy. I am talking very specifically
about cuff arthropathy. Some of these patients I keep going by injecting
local anaesthetic and steroid. But these patients, whatever you do to
them, do not get good motion into elevation. But if you got a good bearing
surface, you increase their rotatory movements, you facilitate their
function. I think that putting in a prosthesis certainly is important
to function. The alternative is to go in and just debride, and I don’t
think that’s anything like as effective.
MO:
What about the rheumaotid patient with a very thin cuff?
JCP:
Our long-term studies of arthroplasty in rheumatoid suggest that the
rheumatoid process in the cuff continues, and that a high proportion
of those patients end up with superior subluxation. This is one of the
reasons why the average elevation in rheumatoid is round about 90 to
100 degrees.
There are some places where synovectomy of the glenohumeral joint is
still popular. I think there is possibly some advantage in doing a synovectomy
in the erosive type. I would really want to do that arthroscopically,
though I haven’t yet got into arthroscopic synovectomy. But over
the years, I have seen some patients who have had previous open synovectomies;
and I have been impressed by how poor the subscapularis was when I went
to do the arthroplasty. So I think arthroscopic synovectomy would be
the choice.
MO:
How do you treat constitutional instability of the shoulder?
JCP:
Largely with appropriate physiotherapy. My experience with this condition
is that it is frequently not recognized. I have been lucky in having
physiotherapists who have developed a special interest in the area.
We see a lot of elite swimmers with this problem, and we have been able
to develop various programmes for them. Of course, one of the biggest
problems is getting the people themselves to understand that they need
to do this regularly for such a long time; but it’s got a high
success rate. You usually find that the ones that present with symptoms
of impingement do very well. Those that are actually dislocating do
less well, and I use a form of inferior capsular shift procedure on
them.
MO:
When you say ‘a form of’, what do you mean?
JCP:
There are a number of inferior capsular shift procedures described.
I tend to do the inferior capsular shift more or less as it was described
by Neer. Normally, I just suture soft tissue to soft tissue, rather
than using anchors.
MO:
What do you think of arthroscopic treatment of instability?
JCP:
I still regard shrinkage as a technique which is under evaluation. I
am very interested in it, but I probably only have a maximum of five
or six patients a year where I have considered shrinkage. And when I
have considered shrinkage, I have sent these patients off to Steven
Copeland, who has been studying these patients. I feel that, in this
way, I am contributing to increasing the understanding, and also sending
the patients to someone who can do the operation far, far better than
I could.
MO:
Do you consider yourself to be a Scot?
JCP:
Although I was not born a Scot, I have been subject to many Scottish
influences. I have been living in Scotland now for 35 years, and I am
very comfortable here. I have long had an interest in Scottish country
dancing, even before I came to live in Scotland. I have learnt to play
a rather antisocial instrument, the bagpipes. The quality of life is
good for my family, and I am able to pursue my professional interests,
combined with a good life style. I can also indulge in my favourite
hobbies – rugby, and fly-fishing.
Maîtrise
Orthopédique n° 112 - 2002, March
