[00:00:00]
MUSIC
Dr. Dua: In my mind, I always think about how long can I delay maybe the inevitable that the patient needs a shoulder replacement.
Dr. Karan Dua is an orthopedic surgeon with a deep admiration for the upper extremity – especially the shoulder. He finds the anatomy beautiful and is fascinated by the complexity of the joint. Which, for injured patients with arthritis or torn rotator cuffs, could mean a total replacement.
But – Dr. Dua has a unique background. He’s one of roughly ten surgeons in the country – and one of the only surgeons in New York – who specializes in reconstruction of the scapula. He’d rather reanimate the shoulder than replace it.
Dr. Dua: Tendon transfers have been performed in orthopedic surgery for decades. We do them all around the body. Very common in the upper extremity. It’s something that we do all the time. What has changed, I think, in the scapular thoracic or shoulder area is that the fact that we now get to do these with [00:01:00] arthroscopic assistance.
MUSIC OUT
Using arthroscopic instruments, Dr. Dua removes the injured tendon and replaces it with a healthy, functional tendon – either from another part of the patient’s body or from a cadaver donor.
THEME
Dr. Dua: What we talk about for tendon transfers, is creating or reanimating the shoulder using functional transfers of tendon and muscles to recreate an action or a synergistic motion that can then allow the patient to move their shoulder or regain strength and mobility.
This is life-changing for many of Dr. Dua’s patients with shoulder issues – who often skew younger, and are athletes or manual laborers. Both the surgery and recovery are challenging, but Dr. Dua believes they are worth it, which is why he's dedicated to personalizing shoulder surgery for every patient
I'm Erin Welsh and this is Advances in Care, a podcast [00:02:00] about groundbreaking developments in modern medicine.
In this episode, I speak with Dr. Karan Dua, orthopedic surgeon at NewYork-Presbyterian and Columbia, about how he hopes to redefine surgical approaches and create a new standard of care for upper extremity orthopedics.
THEME OUT
________________________________________
Erin: Dr. Dua, thank you so much for joining me today.
Dr. Dua: I’m so grateful to be here, Erin. It's exciting to be able to talk about things that I'm passionate about and some more cutting edge and novel things that are happening in upper extremity surgery.
Erin: Yeah, I am really excited to get into it, so let's start at the beginning of that story. Can you tell me a little bit about where you come from and why you got into medicine?
Dr. Dua: Yeah, I actually grew up in New York. I'm from Brooklyn. I come from a family of physicians, so it's kind of my family trade and something that I was born into, but something that I'm really proud to be able to do and kind of serve this community that's given me so much. So it meant so much to me [00:03:00] to be able to come to Columbia and be able to share that with the same people that helped raise me.
Erin: That’s amazing. And so did your initial passion for medicine sort of stem from your family and then how did that turn into an interest in orthopedics? How did that then sort of catch your eye?
Dr. Dua: Yeah, I mean, that's a great question. I think I was always fascinated to orthopedic surgery. I think what makes it so unique and so special is that you have people who are, say, at their worst or have an actual problem that you can create a treatment algorithm or provide a surgery or even it's non operative medicine, and create change. That change is measurable, that change is identifiable, you can see it.
Erin: Yeah. I imagine that that is what makes the work feel so rewarding. And I would love it if you could give me a landscape view of shoulder injuries. So I know some patients develop arthritis after many years, but others – like athletes or laborers, [00:04:00] for instance – are using their shoulders all the time. So what kinds of injuries are you dealing with and what is it like for the patients who have them?
Dr. Dua: I mean, it could be anything. Shoulder injuries can be anything from overhead athletes to people just run of the mill, degenerative tears of the shoulder arthritis, it's one of the most commonly used joints.
I would say we as individuals tend to take things for granted when things are working. [Erin: Mhm] Like you, you wake up, nothing hurts, you go to work and you keep doing your thing. And then, the one day you have something that doesn't work, you think about it. And so it can be anything from, sporting injuries to trauma to overuse. It's such a variable breadth of reasons why you can get an injury to your shoulder.
Erin: And I mean, it's just like what you said, you know, you don't think about it until you do, and then you’re thinking about it all the time, you can't stop thinking about it. And I know that many people will experience shoulder issues at some point in their lives, but when it comes to diagnoses, how [00:05:00] many people really don't fit into these classic boxes because there’s, you know, there’s so much complexity surrounding the source of shoulder pain?
Dr. Dua: We are trained as physicians or specialists to look at certain pathologies with a lens, set in the parameters to understand that problem. So, we look at scapular thoracic disorders in a traditional way. Is it a labral tear? Is it a biceps issue? Is it a rotator cuff issue? But sometimes it's not that, right? [Erin: Yeah] Sometimes you get an EMG scan, you get a shoulder MRI, you get all these different things and things are normal. Yet there is pathology, you can't see it. You can't feel it. You can't understand it, but it's there. The patient's telling you that something is wrong.
Erin: Yeah – and why does that happen? Is it just that historically, orthopedic training hasn’t really focused on injuries to the upper extremities?
Dr. Dua: I don't think it's purposeful. I think it's just a matter of the science is still [00:06:00] evolving. And it's still newer. And I think that's the next, I would say, 25 to 50 years in shoulder and scapular thoracic surgery in the future is understanding these problems. And I feel that's part of my mission is to provide the words to describe it, to understand that and to be able to provide that for people in my community.
Erin: And so tell me about that process, like let's say somebody goes into their primary care provider and they're like, oh, my shoulder's been killing me. I woke up and I don't know what happened. How does that person find their way to you? And what does that timeline or what could that timeline look like?
Dr. Dua: Yeah, I mean, it's, it's so tough, right? We're talking about those people who have issues with their scapular thoracic mechanics and things like that, that they can't get treatment for. And so a lot of times they just get kind of passed around from provider to provider and eventually somebody will diagnose them with some type of scapular dyskinesia or what I now call scapular thoracic abnormal motion. And eventually they'll [00:07:00] go through physical therapy, they'll get a bunch of scans and eventually they'll get injections. And so it comes down this treatment algorithm pathway of is there an actual surgery or actual kind of understanding of how we can help these people?
Erin: I imagine, too, that it's very case by case, very individual problems and trying to understand what's happening in this person's life. And, particularly for issues related to the scapula which can be very hard to diagnose, what are some of the things you do specifically to try to narrow in on the cause?
Dr. Dua: Yeah, for me, I use my physical examination. It's the purest way to diagnose someone, first, you talk to them about what their symptoms are. You try to figure out if it's a traditional source of pain or a non traditional source of pain. Are they tender? Along their coracoid and their pec minor? And then if you examine their back do they have snapping scapula or periscopular pain when you palpate them? Do you feel something? Do you see visibly that their scapula is [00:08:00] winging? Is the scapula moving abnormally, which way is it moving? Why is it moving that way? If I stabilize it or if I reposition it, can I make the scapula move normally.
Once you have your physical exam that's pure and you believe it and you trust it and you understand it, then you can nitpick and choose different type of other modalities like MRI or CT scan or EMG or different things like that to help either narrow down your diagnosis or help exclude other detracting factors that may convolute the picture that this is what's happening.
Erin: I love that. I mean, I think that it sounds like it's, it's a collaboration between doctor and patient. You have to be working together and hearing what they're experiencing and what they're telling you and not just relying on what various tests can tell you about what's going on.
Dr. Dua: No, I mean, that's great, right? We do have answers and we do have, possibly a way to help you whether it's not surgery, right? It could just be more dedicated physical therapy. It could be more dedicated [00:09:00] injections, who knows, right? At least there is this balance where there's a give and take between you telling me what's going on and me trying to help you figure out what's going on.
Erin: Right. And you know, the scapula, I will admit to not having spent a lot of my life thinking about so far, but now I'm, I'm very intrigued because, it sounds like there are so many different ways that things can go wrong, which I guess is true for most parts of the human body. But there are also so many opportunities to repair. And I was curious about how many surgeries or types of scapula surgeries do you perform and what exactly are you repairing?
Dr. Dua: I can't even count them. There's so many. Everything comes down to scapular thoracic abnormal motion. Abnormal motion or scapular winging, we no longer call scapular winging, we call it scapula thoracic abnormal motion or STAM. S-T-A-M. [Erin: Okay] That’s kind of the atypical pain that I'm talking about. Also, around the shoulder, atypical [00:10:00] diagnoses or atypical causes of pain could be entrapments of nerves. I put them into a category of structural problems, meaning that they have a nerve issue, they have muscle damage, they have an injury after surgery, for example, when they do a lymph node dissection, they injure the spinal accessory nerve.
These are what I call structural causes of STAM that are actual problems with the nerve or the muscle and the muscle tendon unit that cannot move the scapula in a balanced and rhythmic way. It means the rhythm in which the scapula moves in relation to the shoulder is abnormal.
Erin: So something is out of alignment.
Dr. Dua: Correct. The balance or the way your mind is telling your shoulder to move is not synchronous. The analogy that I use is a seesaw. It is an imbalance of that seesaw, where the pectoralis minor muscle in the front of the scapula, in the coracoid, that frontal projection, [00:11:00] that's pulling your scapula down. So what's going to happen? Your scapula is going to wing out. It's going to wing out from the back, if the scapula is tipping forward, if the seesaw is imbalanced, the space behind the pectoralis minor is getting constricted. So most of the time for patients with physiologic STAM, you can simply balance the seesaw by releasing the muscle in the front called the pec minor.
Erin: The decision tree also for each patient I imagine is, is very individualized, very, very complicated. I want to kind of pivot to talking about that in the context of shoulder replacement versus shoulder reanimation. And so to get a sense of just sort of shoulder replacements in general, which is one of the most commonly performed surgeries in the U.S. is that right?
Dr. Dua: Yes. It's becoming increasingly common. I think the way to look at it between shoulder reanimation and traditional replacements or things like that is why will you do one or the other.
Erin: Yes.
Dr. Dua: Right, I think that is the biggest thing that you have [00:12:00] to distinguish between the two. When we talk about shoulder reanimation, which I want to champion more and more, is how do we reconstruct the shoulder without giving someone a traditional replacement or a rotator cuff repair if that's possible.
Most people come in, they have a rotator cuff tear, you can fix it, you can put it down and they do well, in an older patient with arthritis, you should do a shoulder replacement because that's the right surgery for them, because you can't reconstruct the tendons around the shoulder. [Erin: Right.] You want to do that because that gives them the best biomechanical chance of using their deltoid to basically power their shoulder.
Erin: Because the cuff will just continue to degenerate over time, even with repairs.
Dr. Dua: Right. It's atrophied. You can't repair it. Even if you fix the tendon it won't work anymore. Now, what is shoulder reanimation? In my mind, I always think about how long can I delay, maybe the inevitable that the patient needs a shoulder replacement, but buying [00:13:00] someone 5 to 10 years of a functional shoulder to me is a win. That's something that I think most people want. Because traditional shoulder replacements, you have a weight restriction. [Erin: Oh, okay.] Right? You can't, you can't lift more than 10 pounds above your head generally, it's, it's really frowned upon because you're going to really wear out those replacements.
What we talk about for tendon transfers, is creating or reanimating the shoulder using functional transfers of tendon and muscles to recreate an action or a synergistic motion that can then allow the patient to move their shoulder or regain strength and mobility.
Erin: So when you're deciding which tendon to transfer, what are some of the factors that influence that decision?
Dr. Dua: You have to look at age, so they have to be younger. People with older physiologic status tend to have poorer bone, don't have as robust tendon and muscle quality to be able to really power the transfer and to have a successful outcome, they have to be pretty active. They [00:14:00] have to have no arthritis generally, or very minimal arthritis. Now, how you decide which tendon to transfer is, you want to donate a tendon or a muscle that is viable and functioning. You want to donate a tendon, with its muscle, obviously, to the area that's basically in deficit. In which they have similar actions, or similar lines of pull. Because if you transfer something that doesn't have the same pulley or the same line of action. It is very difficult to cognitively repattern how you're going to move your shoulder after the transfer.
Erin: Right, so you’re able to more intuitively use these new tendons in the way that you have done before.
Dr. Dua: Exactly. And the rehab is much easier too, because your mind doesn't have to think about changing the mechanism of action of that tendon.
Erin: Can you sort of, like, walk me through what that would look like play by play with this, with this approach [00:15:00] that you're using.
Dr. Dua: Tendon transfers have been performed in orthopedic surgery for decades. We do them all around the body. Very common in the upper extremity. That's something that we do all the time. What has changed, I think, in the scapular thoracic or shoulder area is that the fact that we now get to do these with arthroscopic assistance.
So let's start with the lower trapezius tendon and we can use that for an example. An incision is made in the scapula or what I, what we call is the house of the lower trap where the tendon is inserting. You find it, you elevate it off to whatever you want to use, electrocautery, etc, etc knife, whatever. You cut it off sharply off its insertion, right? Tendons insert on the bone. You have the tendon, it won't reach the humerus. It's too short. [Erin: Okay] But the reason why we want to use it is because the line of pull of the tendon works really well in line with the rotator cuff that's torn and irreparable.
So now how do we get it to where it needs to go if it has to go all the way up to the shoulder and the humerus, but you're all the way back in the shoulder [00:16:00] blade and scapula and it can't get there. So what you do is you extend it. Using a cadaver graft. And we use an Achilles tendon allograft. It comes with a big bone block, we cut off the bone block, but it has a nice juicy tendon. And it fans out to have an extension. Then you arthroscopically will go into the shoulder with, you know, whatever your arthroscopic instruments are. You clean out the shoulder, you figure out where you're going to put it.
And then, I will actually pass the allograft from the back of the scapula, there's no incision. All you have is small poke holes in the shoulder. You'll take a long grasper from in the shoulder. Bring it out the back into the scapula area, take that graft and transfer it into the shoulder arthroscopically.
Erin: Okay. That’s amazing. When it comes to the post operation healing time or, uh, physical therapy time, what are sort of the differences between shoulder replacement and shoulder reanimation?
Dr. Dua: Yeah I think shoulder replacements are [00:17:00] one of the best surgeries that were ever made. Because I think the therapy is so predictable. You're in a sling for about three to four weeks. You're doing it for comfort. Some people let them start doing pendulums, like almost as early as next day or even a week in.
It's not as easy as the functional recovery of that is much more convoluted and it's harder, right? Because what do you need for this to be successful? Two things, when you transfer. number one, you need the site from which the tendon is coming from to heal. We talked about the lower trapezius and the Achilles graft, and when you weave them together, that thing has to scar in and heal. If it doesn't scar in and heal, it's gonna rip, you don't have a transfer anymore. So, you don't move those people for around eight weeks after the surgery.
Erin: That is, that is quite a long time.
Dr. Dua: Quite a long time because you need that transfer to heal.
Erin: When you do follow up with your patients, what sort of responses do you get?
Dr. Dua: It's crazy. Everybody says something so different. The stories [00:18:00] are so unique and everybody has a different response and I think that's probably one of the most rewarding thing about this is being able to figure out the pathology and to provide a treatment. That a lot of people were told is impossible or that patients were crazy, most of these patients are young, early 20s, mid 20s. They're not like 50, 60 year olds.
Erin: Right, you, there should be nothing wrong with you, it's, you're probably fine.
Dr. Dua: Right.
Erin: I'd love to hear what you are most hopeful about in the next five to 10 years when it comes to this field.
Dr. Dua: Yeah. I mean, it's evolving. It's growing. What I'm hoping over the next five to 10 years is to create really a program here at NYP of providing a space or a tertiary or quaternary referral center, or even primary, a distinct area and place where you can get these type of novel cutting surgeries.
THEME IN
We have really brilliant minds from diagnosticians to people who are so good with ultrasound, who can do injections in the [00:19:00] pec minor, can do all these incredible ultrasound mapping of the brachial plexus to top notch occupational therapists and physical therapists and social work I think with the reach of NYP and our footprint in New York, I think it can become something so special.
Erin: This was such an inspiring conversation. Just thank you so much for being here today. I really enjoyed our chat.
Dr. Dua: Thanks for being able to hear my story and be able to share what we're trying to do here at NYP and what we're trying to build. And, thank you so much.
________________________________________
Erin: Huge thanks to Dr. Karan Dua for taking the time to speak with me about his innovative approaches to surgical management of the upper extremity.
I’m Erin Welsh.
Advances in Care is a production of NewYork-Presbyterian Hospital. As a reminder, the views shared on this podcast solely reflect the expertise and experience of our guests. To listen to more episodes of Advances in Care, be sure to follow and subscribe on Apple Podcasts, Spotify, or wherever you get your [00:20:00] podcasts. And to learn more about the latest medical innovations from the pioneering physicians at New York Presbyterian, go to nyp.org/advances.
