A Disjointed Post

Surgery is the topic of today’s post, namely because I had shoulder arthroplasty last Tuesday. The technique was reverse shoulder replacement and, as you ask, what is that? be assured that I will get there. We have to cover a little anatomy, anthropology, Popular Mechanics, history (of course), and technology along the way.

Fish Gotta Swim, Horses Gotta Run, Humans Gotta Throw Spears

Let’s talk about joints, specifically shoulders, ball-and-socket joints, and the term synovial. I had originally thought that fish had no ball-and-socket joints, and I was going to claim that it was the reptiles, crocodiles crawling out of the water, who began to develop those movable arm and leg joints rather than fins. But it turns out that, even at the beginning, fish had some types of ball-and-socket joints in their jaws, in their vertebrae, and even in their fins.

Synovial=(Greek) put together+egg=the shape of certain joints

The word synovial is important here because it means that within rigid bones, there is a hollow part and a bumpy part that fit together. Even with fish, there were hollow/bumps that fit together in fins and jaws which allowed for more flexibility and rapid movement. When reptiles developed the ability to walk on land and swim in the water, those fins turned into longer bones with multiple places for movable joints.

Crocodiles on their back legs have a fitted ball joint, however, no socket. It allows them to waddle on land and still swim fast in the water, as many a stray dog has found to their peril. The ancestor reptiles of dinosaurs–you knew I was going to get to dinosaurs–developed the ball-and-socket joint in their hips, which allowed them to grow tall upward, become bipedal, and move fast enough to dominate all of the earth, eclipsing their crocodile cousins.

By the time that mammals took their turn at domination, ball-and-socket joints had become more common as an evolutionary feature, though bodies used them in different ways. Horses, for example, have a flexible joint in their shoulder but not a ball and socket joint as we humans do. Their shoulder joint allows for strength and movement but only forward.

When primates developed, their adaptive specialty was a ball with a receivable cup in the shoulder, which could rotate with far more flexibility and rotation of their front limbs. They couldn’t move as fast as a horse, but now they could use tools and throw things. Like spears. Or slingshots.

I Need This Like a Hole in the Head

Now that we’ve covered basic anatomy, let’s talk about cutting people open. It seems that rather quickly after inventing spears and slingshots, people started throwing them at each other. Humans are as territorial as other animals. Fairly shortly after that, as people got hit in the head with said slingshots, they needed a new technology called medicine to help them out.

Trepanation = (Greek) to bore a hole, a drill = to drill a hole in the skull

Six thousand years ago, give or take a few years, during the Neolithic or Linear Pottery time period, surgeons were drilling holes in people’s skulls. European archaeologists found tons of skulls with holes drilled, many of which had repaired themselves. But the earliest archaeologists thought this was accidental, and it never occurred to them that humans, barely past Neanderthals, could perform brain surgery.

Examples of this technique, called trepanation, were ultimately found all over the world. It was a drilled skull found in South America in the 1860s that proved it was done by a human on purpose and successfully. In another famous skeleton found in ancient Greece, a woman had clearly been hit with a slingshot, and developed swelling in her brain that needed to be relieved. The relief was the hole drilled in her skull which clearly healed over and added years to her life. Thus, the first ancient surgery was, in fact, brain surgery.

You Can’t Just Stick Metal in People and Hope for the Best

Yet despite the 6000-year-old head start, surgery and medicine advanced very slowly across the cultures and the centuries. There were famous surgeons in Egypt, China, Mesoamerica, and Africa. The Arabs developed sophisticated medicine after learning some of the techniques of the Greeks, but the medieval Europeans were pretty focused on leeches, so advancement in medicine was very slow. Even during the Enlightenment, when scientific techniques and experimentation became more refined, cutting people open didn’t work very well. There were attempts as early as the 1560s to use metal to fuse broken body parts together, but there was one big problem: infection.

Doctors could cut people open or saw off broken limbs, but when they sewed them back together, infection rates were sky-high. Surgery didn’t advance because there was no anesthetic, lots of bleeding, and post-procedural infection. As they used to say, “the operation was successful but the patient died.” The turning point came in the 19th century between some scientific advances by the French, Hungarians, and English.

Louis Pasteur noticed, among the many things he noticed, that infections seem to be related to little microorganisms, i.e. germs. Germ Theory was born. Then, a Hungarian obstetrician, Ignaz Semmelweis, noticed that there was a high rate of death of women in childbirth by doctors who had also been performing autopsies in the morgue next door. Semmelweis started the new practice of having the pathologists clean their hands with a chlorine solution before delivering babies. Voila! The incidence of women dying from puerperal fever dropped dramatically!

The English physician, Doctor Lister, put it all together and decided to implement a technique of spraying the disinfectant carbolic acid over patients during surgery. Patient infection plummeted. The spray was a little tricky, as the smell and touch of the acid on the physicians was a bit toxic. They worked out the details, and surgical history was made.

On Needles and Pins (and Screws)

It’s no accident that Mary Shelley’s Frankenstein was written during the Industrial Age. Certainly if inventors and scientific tinkerers could generate machines that used flywheels, pulleys, replaceable parts, and electricity, then why not do the same thing for bodies? With Dr. Lister’s magical carbolic spraying technique at the ready, physicians who like to build bird houses in their spare time were ready to attach metal bars, screws, and ball-and-socket joints to bones.

Arthroplasty= (Greek) A bendable part of the body, a tool, a joint + molded or formed = surgery which replaces a joint

The first shoulder replacement surgery happened back in the 1880s. Themistocles Gluck likely pioneered it, but apparently didn’t publish, so he doesn’t get credit. French physician Jules-Émile Péan used platinum and rubber to replace the shoulder joint of a waiter, and so he is credited with the first successful arthroplasty. The waiter was very pleased, at least for a while, but then he did develop an infection. Needed to talk to Lister.

By the 1950s, shoulder replacement had become somewhat routine, although American physician Charles Neer noticed that if there were joint tears, like rotator cuff tears, the surgery didn’t work as well. Either from reading issues of Popular Mechanics or watching “This Old House,” Neer hit upon the idea of switching the socket and the ball. Reverse shoulder replacement surgery was born. Truly Frankenstein stuff.

Some of the mechanical designs worked better than others but again, leave it to the French, to create the optimal “Frankenstein” device. Pun intended. French physician Paul Grammont created a working design for a socket-and-ball joint that is in standard use today. One of his key improvements was noticing that the deltoid muscle, the triangular muscle that covers the shoulder joint, could work better if the center of shoulder with the replaced bits of metal was shifted lower (distally) and closer to the body (medially) compared to its natural position in the shoulder joint.

As a publication on the history of shoulder surgery puts it,

In 1991, the second generation of Grammont’s design (Delta III) medialized the center of rotation to the native glenoid surface by changing the glenosphere from 2/3 of a sphere to ½ a sphere. Additionally, the baseplate (metaglene) included a central press-fit peg and two divergent 3.5-mm screws designed to resist the shear forces at the bone-implant interface. The initial Delta III glenosphere screwed onto the metaglene with peripheral threads, although in some cases this mechanism unscrewed and the design was later changed to a Morse taper with a central countersunk screw.

Of course, that reads like an IKEA manual to me but whatever works! Viva la chirurgie!

Here are some things I have verified are tricky to do with one arm:

• Tying shoelaces
• Flossing teeth
• Opening a jar
• Fixing a wedgie on the other side while lying on the good shoulder
• Writing a long blog about surgery

The Miracle of Technology

Merci, Dr. Gammon but that’s not the only technology that is making this manageable. In addition to the fancy switching ball with socket idea, medical scientists also invented a magic nerve blocker that has significantly reduced my post operative pain. So far. I’ve had three other surgeries, and I’m experiencing less pain than I did in those other cases, the first few days after. Talk to me after the weekend, when the nerve blocker wears off, but I’m very hopeful.

Secondly, I thought sutures that disappeared were magical, back in that 1973 Columbo episode with Leonard Nimoy. Decades later, however, they not only have disappearing sutures, but also glue and a waterproof dressing cover that so far seems to be reducing infection and making my life a lot easier. Again, talk to me in two weeks when the dressing comes off, but I can shower without wearing a plastic bag haha!

Lastly, if you were curious as to whether I used AI for this blog, I did not. Well, technically, I did use Google AI to create the Frankenstein robot drawing at the top, because I couldn’t find one already drawn that met my specifications. It was hard to create this blog with only one hand; typing quickly became a pain in the patootie, even though I’m pretty good with one hand. It turns out that the most useful thing for a one-armed writer is decades-old technology–the built-in dictation device in Microsoft Word. I don’t need no stinking voice commands. I don’t need a robot to write instead of me. I just need a robot to write exactly what I’m thinking. And that has worked quite well.

April will be A-Z blogging season, and, in my head, I’m planning to do it. It’s going to be a little challenging if it takes 4 hours to dictate every single blog, every day, 26 times. However, practice will make perfect so what better way to start but with today’s post?