On the shoulder that was "too complex".
A note for GPs, for patients, and for the surgeons who sometimes pass these cases on. Complexity is not a liability in our practice. It is the chapter the practice was designed to write.
A patient walks into clinic this week with a folder. The folder is thick. There is a 2019 MRI, a 2021 ultrasound, a 2023 CT, three operation reports, and four letters from three different surgeons. The last letter, from a surgeon she respects, says her shoulder is "too complex for local management." She has driven three hours to bring me the folder.
She apologises for the folder before I have read any of it.
There is nothing to apologise for. This is what I do.
Patients are sometimes referred to me after being told their case is too complex for the local pathway — a failed previous repair, significant bone loss, a revision arthroplasty, a massive irreparable cuff with co-existing arthritis, a fracture-arthroplasty conversion. These referrals are not a problem. They are the practice.
A few things I have learnt about these cases.
Complexity is rarely a single problem.
A "complex" shoulder is almost always three problems stacked on top of each other. The first thing I do is pull them apart. The bone loss is one problem. The soft-tissue compromise is another. The patient's expectation, often shaped by years of unsuccessful treatment, is a third. Each is solved separately. The combined plan is the answer.
The previous operation is information, not a verdict.
I am not interested in second-guessing the previous surgeon. They made the best decision they could with the picture in front of them. What I want to know is what the operation found. The operation report is the most important document in the folder.
The CT scan often tells me more than the MRI.
In a complex revision shoulder, bone stock is the rate-limiting variable. CT with 3D reconstruction shows me the glenoid I have to work with, the augments I might need, the components that are realistic. I will often organise a planning CT before the second appointment.
The plan is bigger than the operation.
For complex cases, the operation is the smallest part of the plan. The bigger pieces are the rehabilitation protocol, the realistic functional goal, and the communication architecture — with you, with your treating physiotherapist, with the GP four hundred kilometres away who will be the local clinical point of contact afterwards.
For the GPs reading this: if you have a patient whose shoulder has been described as too complex, that referral is welcome. The complex case is the chapter this practice was designed to write. Send the folder.
— Joe