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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.
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.
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.
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.
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 - March 2002
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