Episode Transcript
[00:00:03] Speaker A: Welcome to the Ortho Joe Podcast, a joint production of the Journal of Bone and Joint Surgery and Ortho Evidence.
Join hosts Mohit Bhandari and Mark Swankowski as they discuss current topics and publications in the world of orthopedics and beyond.
[00:00:19] Speaker B: Well, good morning, Mo.
[00:00:20] Speaker C: Good morning. Good morning.
[00:00:22] Speaker B: It is summertime in Minnesota and we're under a heat dome here.
[00:00:26] Speaker C: Yeah.
[00:00:26] Speaker B: Has been very, very, very warm. But I want to just alert you to my shirt.
[00:00:36] Speaker C: Oh, look at that.
[00:00:38] Speaker B: Because it's. It's come to my understanding that the CBC is considering eliminating Hockey Night in Canada, which has been a big part of our life as a hockey family for 25, 30 years. So it's a state of emergency, in my view, and I'll be participating in lobbying the controlling ventures of your broadcasting national company to stop this insanity.
[00:01:07] Speaker C: Look at this advocacy. Look at this advocacy. I appreciate that. All Canadians appreciate that I'm just sipping away, sipping away on a. On a warm, warm coffee on a very hot day. They do say that, right? They do say that Having some hot drinks on a hot day is not. Not entirely counterintuitive. So, anyways, I'm enjoying that.
[00:01:26] Speaker B: It quite goes along with your passion for chopping holes in ice in the wintertime and jumping in for five minutes cold.
[00:01:34] Speaker C: Is the cold hot in the hot?
[00:01:35] Speaker B: Yeah.
Anyway, it's great to be with you this morning because we have a very important guest in my career, Dr. Rick Matson.
Rick has absolutely wonderful and important career, particularly in the area of shoulder surgery. He was the vice chair when I started a residency and was very helpful in formulating and supporting my academic career. Got me started in the use of the laser Doppler, which dominated my early career and led to a year of research. And then was chair when I came back to Seattle in 1988 and supported the work we did at Harborview. But most importantly, I would say, for the orthopedic community is Rick's work in the shoulder. He was one of the very early people that went to visit Dr. Charles near and then came back to Seattle and has been at the forefront of the developments in shoulder surgery, including the classic book on the shoulder with Dr. Rockwood, developing a shoulder implant extremely widely used and is now, I would say, the major thought leader in shoulder surgery. Always been a reflective individual who is now asking questions about why the heck we're not learning from poor results.
And I believe it was you, Mo, that asked him to write a piece for the Journal about the whole issue.
I'll stop yammering. Her In a minute. But one of the things that always has interested me and I had a recent discussion with Rick when we were in Seattle is why haven't we seen the disasters published in large numbers with reverse total shoulder arthroplasty? And we got to talking about this whole phenomenon because literally we haven't seen like we saw with metal on metal or surface replacement the publication of large series of disasters. And that's what got this whole discussion going with me. So Rick, welcome.
And let's just have you start off by talking about the whole issue of why the heck haven't we learned from our mistakes in shoulder arthroplasty.
[00:03:56] Speaker D: Well, thank you for inviting me. And I'll just point out that it's been 76 degrees and sunny here and just.
And my office is in my backyard.
I spent a lot of time out there enjoying the pool in my un air conditioned home. So ouch.
[00:04:15] Speaker C: Ouch.
[00:04:17] Speaker D: Again, thank you for inviting me and it's a real honor to be speaking to two of you for whom I have great respect.
So I would like to say that we're not asking the right questions.
And we are asking questions like what is the revision rate after reverse total shoulder? Or what does the MRI look like after a rotator cuff repair?
Are our current technologies enabling precision of implantation of orthopedic devices?
My comments are not going to be focused on the shoulder, but I will use the shoulder as an example. So there's been a wonderful paper that really enlightened me a lot, written in 2025 by Omali, published in PLOS One.
And what she did is she asked a bunch of people that had had reverses what their function was using the Oxford shoulder score. And guess what she found 27% had poor function.
So again, she's asking the right question, just like Codman did. She's asking, how are you doing?
She's not asking what is your range of motion? What do your X rays look like? Did you use a lateralized implant or a medialized implant?
And I think one of the reasons that we are ignorant of the number of failures is number one, we're looking at surrogates that are not necessarily relevant, like revision rate.
Well, all three of us know that the prospect of having a patient with a painful arthroplasty and trying to decide if you're going to revise them when you really don't see anything. The matter with the X ray is daunting.
And we know that the revision, the success of revisions in reverses is horrible.
You know 50% of them do poorly.
So we start out with 25% of them doing poorly. And if we revise Those, we have 50% that do poorly.
So I think the right question that we need to be asking is, how are you doing?
And that involves following our own individual patients, because what we want to learn is, who is not doing well?
And to ask the question, what might we have done differently to prevent that adverse outcome, which is, of course, Judea Pearl's concept of a counterfactual.
And so what I'm hoping that I can, in a small way, encourage people to do is to engage this kind of introspection.
And if we go back to the basic principle that the surgeon is the method, what goes on in the Australian registry or what happens at the Mayo Clinic is less relevant to the individual surgeon than their own individual practice because they are using their techniques on their patients. And what happens in Minnesota or in Toronto is interesting, but it may not be relevant to what happens with their hands in their patients.
So if we start out with the basic precepts that the surgeon is the method, the patient is the objective, and we are concerned about our own outcomes, and the only way we're going to learn those is to ask the right question. And I think that gives a platform that can be generalized across orthopedics, because it doesn't matter if we're talking about a hip replacement or an oncology procedure or anything else. If we ask those three questions and recognize the importance of knowing our own outcomes, I think will be a lot better. So what's progressed since the publication that we were discussing is I had originally the idea that this would be some sort of a generalized concept and we could get a whole bunch of people together and they could pool their outcomes. But the more I thought about it, and credit my colleague Dr. Menendez, for sharing this sort of thought of evolution with me, is that that was the wrong focus.
The focus has to not be on multicenter studies, but the focus has to be on individual, local practices. And the best gift that we can give practicing orthopedic surgeons is the idea that they are in control of what they do. They don't need to be swayed by industry saying, you can get a more precise outcome with a robot or a better outcome with patches applied to your rotator cuff repair. They need to decide what's not working in their practice. And the only real reason for transitioning to something that the vendor is trying to sell you is does it solve a problem that you have with your patients?
And so it's the whole idea of going from general to local that I'm trying to advocate.
[00:09:19] Speaker C: Can I ask you this, Rick? I mean, everything you say sounds absolutely logical. And you would think, why isn't everyone thinking this way? Like, this is such a, you know, like it's an evolution of thought rather than even a revolution. But Mike, I guess maybe at a personal level, when did you begin to really introspect the way you do? Is this something that, like, there was a moment where you just start, you know, because the system when you're a resident is, pushes, you know, be productive. And there's all these new gadgets, there's all these new things, randomized trials, you know, just go, go, go, go, go.
How do you fight that? Or I guess if you're talking to those who are probably in the midst thinking this is just not feasible for me, this doesn't make sense. How do you help someone make sense of this? And how did you make sense of it earlier in your career?
[00:10:10] Speaker D: Thank you for the thought provoking question.
It's been an evolution, but part of it is to recognize that when I have a problem with a patient, I can go to the literature and see what other people have done to try to address the problem.
But often the answers that I come up with by looking at multicenter studies or RCTs or whatever don't seem to be relevant. In other words, I've got this patient who has pain that I don't understand.
So what I have done, as in the example that you know of, is I've tried to take that person with one adverse outcome and compare them to similar people in my own practice that didn't have an adverse outcome. And to do the math of what's the difference between the two.
And I find that really exciting. And I've learned that what is most relevant to each individual surgeon is their individual outcomes. And so the best answer to your question is it's been a progression for me, going from the general to the specific and trying to let surgeons know that they have incredible power to improve their own outcomes. It just involves a little work, including following people along and finding out who does better and who doesn't, just like o' Malley did. I mean, I would have never guessed that 27% of people with reverse arthroplasties had poor outcomes. And what's Even more interesting, Mo, is that of all those with unsatisfactory outcomes, only 5% were surgically revised. And what that tells you is that the surgeon just said, gosh, the opportunity for making this patient better because they have an uncomfortable shoulder seems low. And even more importantly, the patient says, wow, that big operation you did on me, I'm still hurting. You're now telling me that you want to do another operation on me and what is the likelihood of that outcome?
So I think that again, it goes back to trying to make sure that we ask the question that is going to transform our practice.
And as you both know, there is a huge industry push.
And I even heard again a view medi talk last night about how biologics are going to transform our treatment of arthritis.
Well, it may be, but it came across as a sales pitch. And I think that we are driven so much by industry that we have to again ask the question, is this new technology that's being proposed going to help the problems that my patients have?
[00:12:53] Speaker B: Rick, you've been looking at the patient perspective for decades.
You developed this simple shoulder test, which was a validated tool that I think is fairly widely used in shoulder research, but it's not in widespread use in the non academic world, I would guess. I don't know that for a fact, but I'm just guessing. And it seems to me that the incentives that we have in our current system are against following our patients, particularly those that are not happy. And have you given any thought as to how you, as a leader in shoulder surgery, can help develop or advance the circumstances where it's in the individual practicing surgeon's advantage to actually follow the patients who have poor results in a more comprehensive manner? Have you thought about ways to develop incentivization to do this?
[00:13:56] Speaker D: Well, just a word about the genesis of the simple shoulder test. As you know, my late partner, Doug Herman, was the power behind developing that. And what we wanted was just some simple questions that any patient could answer using a pen or a pencil and a piece of paper, and then we could send that to them and they could send it back. And the idea was that we wanted to capture the highest percentage of our patients.
So if we make the follow up so difficult, like the patient has to come back and have range of motion and everything else measured, we're automatically going to lose at least half of the patients because they're not going to want to come to Seattle.
So we have to develop a method for increasing the number of patients for whom we have follow up, because only if we do that will we get a real idea about how our practices going. And to your point, who is not doing well?
The second thing about the simple shoulder test is rather than coming down with a Number it just asks about 12 functions, which I think is really important to understand. A patient says they're not doing well, those questions can give you a little bit of insight into whether their problem is pain or is it weakness or is it stiffness or what is going on. So I think that the sales pitch behind a tool like the simple shoulder test is, enables a lot of capture and it gives you insight to who's doing well and the people that aren't doing well. Those may be the people you want to get on the phone and say, how are you doing?
And the only incentive for really doing that is if you care.
If you don't care, then you shouldn't bother. And if you want to tell your patients that most of my patients do great, that may suffice for individuals and it probably is true for most individuals. But I'm going to again go back to the point is you only know the answer if you ask the question. And if you don't ask the question, you are ignorant to how your patients do. And I think the o' Malley study points to that nicely, that the only way she got those data, and it was only 29,000 patients that she had in her study, but the only way she got that information was by asking the question. But you have to have the courage to ask the question because when you ask the question, you may not like the answer.
I am so much worse than I was before you operated on me. You have to be prepared for that. And you have to have some thick skin. But at least it says one thing, which it says to the patient, I care about you enough to follow up.
And if you're not doing well, I feel bad about that and I'd like to see if I can engage with you and figure out a what we can do for you now and maybe what we can learn from your experience.
But it's a hard sell because people are busy. But the point about the Codman end result card that he sent to people or the simple shoulder test is that the bar is low.
We're not asking them to come, we're not asking them to get an X ray, we're not asking them to do anything other than fill out a piece of paper and mail it back in.
So the whole exercise is lowering the bar to maximize the number of people that will respond.
Great.
[00:17:22] Speaker C: I might ask a forward looking question, Rick. You know, before we jumped on and recording, you had mentioned that so much about everything you're doing is in beta version and I took that somewhat jokingly as well. That's great. That means that you're always revising the way you think about a problem based on new learnings. So you publish. And I encourage those listening or watching this to really take a look at the November 19 issue in which Dr. Mattson talks about objective ignorance. And I encourage you to look at the April 15th of 2026 issue in which, again, Dr. Matson, along with colleague Dr. Menendez, talks about surgical failures. What's next, Dr. Mattson?
[00:18:05] Speaker D: I think that the idea is to try to make the message so simple that every orthopedic surgeon can understand it and to tell them that if your real commitment is to getting the best results, you can for each patient, you just have to hold yourself responsible.
And that means you have to hold your feet to the fire and be prepared for the bad news.
So my odyssey now is just to try to get that message out as much as I can.
And as you know, I'm a little bit of an industry contrarian, which is why whenever I'm invited to a meeting, the most common topic they're asking me to enter into a debate on is the case against robotic surgery.
That's what I get invited to speak on more than anything else, which is followed by six papers on how wonderful robotics are.
So I think that what's next for me is just to continue to try to emphasize the relevance of asking the right question and to say that the beauty of that is you can make yourself better.
It's just like it's a little. Since you both are hockey fans, it's a little bit like looking at the game film.
And when things didn't go well, you said, gosh, if only this player or I had been better at that, I might have prevented that goal that cost us the game.
And so one of the things that is really important to emphasize is how do you spell outcome?
Is outcome revision rate?
Is it the mri?
Is it the precision?
Or what do you want to really measure in terms of the outcome? Because if you don't get the answer to that question right, then you won't be informed.
People are often talking about failures.
They talk about, again, a shoulder example. Glenoid component loosening is a cause of failure. Glenoid component losing is not a cause of failure. The cause of failure was the technique with which that glenoid was inserted.
And so to say that we've now just. And you see all these multicenter studies which categorize failures, infection and instability and so on, but they don't ask the next question, which is, why did that happen?
So it's just like the old story that the war was lost because the general's horse stumbled.
Why did the general's horse stumbled? Well, because his. So you could say that was the cause of the loss of the war. But if you track that back, it stumbled because he didn't get to the war because his horse stumbled. His horse stumbled because the shoe fell off. And the reason the horseshoe fell off is that the farrier didn't have enough nails to put it in.
So the solution to that, the next time this comes up is make sure your farrier has enough nails to put the horseshoes on properly.
And I think that we let ourselves off too easy by just categorizing failures rather than trying to say, again, hats off to Judeo Pearl, asking what could have been done differently to prevent that.
[00:21:34] Speaker C: Yeah, it reminds me, Mark, I'll jump in as my last comment here, but it reminds me of, you know, a riveting series of interviews with Richard Feynman around the choice of this Challenger space shuttle. I remember this mid-1980s or something where that O ring and the, you know, the rocket booster and going back, back, back, back, back to his experiment. And I think that's it just. It resonates. What you're saying is there's so many things we take as sort of, you know, as. As the root cause. And when they're not even close to being the root cause, we got to keep going back.
[00:22:07] Speaker D: And you remember that the way he demonstrated that was by.
In front of a bunch of disbelievers, he took an O ring and put it in the ice water.
[00:22:14] Speaker C: That's right.
[00:22:14] Speaker D: So that you could break it easily with your hand. So sometimes it takes a lot of convincing.
But I think that, again, he identified what the problem was by going back, as you say, to the root cause and not just saying it was O ring failure. But he asked, why did the O ring fail? Just like, why did the horseshoe fall off? Yeah, it was great.
[00:22:36] Speaker B: It's one of the basic fundamentals of the Kaizen system that the Japanese developed in lean production is five whys. You have to keep asking why five times until you can get to the root cause reliable. I've got one more question for you, Rick, and then I'm going to let mo conclude this session. But you taught me the examination of the shoulder and basic shoulder surgery. I could still do an open bank heart if one of my partners asked me to do that, thanks to you. But one of the things I observed in the clinic is you were very, very careful about patient Selection and patient factors have a very, very important impact on outcomes, on functional outcomes. And can you just say a few words about patient factors and how do you advocate for individuals taking more time for elective procedures in figuring out who may or may not benefit?
[00:23:35] Speaker D: Thank you. So again, Mo, I'm still in perpetual beta on this one, but I've changed the way I go into a patient's room.
And the first thing I do is I sit on the. Usually I sit on the garbage can, which is the sort of most convenient thing to sit on in the exam room because I want to look at them right in the eye. And I say, what questions can I answer for you? That's the first question I usually ask the patient because I want them to drive the conversation.
And if they say, I need my drug prescription refilled or I need my help with my LNI paperwork, or I can't sleep at night, or I can't throw a baseball, all of a sudden they have framed the conversation. And now I know what that patient's priorities are because they're my customer, I have to respect them. So the first thing I do is try to let them frame the conversation.
And then the last thing I do is to look at x rays or MRIs.
The next thing I do is to ask them to show me what your shoulder does that you don't like. In other words, can you show me what bothers it when you. What positions bother you or whatever?
And because I'm sort of in a slow roll with respect to the decision about surgery. But in this conversation, I discover a number of things, which is how much insight do they have to their own problem?
How much education am I going to need to do to bring them up to speed?
I often tell them that we're not going to discuss surgery at this visit.
And I used to say we never kiss on the first date. So, you know, I really want to slow roll the whole process.
And then when we get down to if they are considering surgery, I really go through the factors that are going to influence their outcome. What is their support system at home? Who's going to look after them after surgery? What is their nutrition level? If somebody has a BMI of 15, I've got to have a long talk with them about nutrition, which is, again, something that's involved just over the last year to recognize how important it is to understand that if you operate on somebody, you're giving their whole metabolic system a huge challenge that it has never seen before.
And so I've got to emphasize to them that they have to have the building blocks to heal after the surgery and then to just make sure that they are informed about the possible outcomes, the importance that they have and their family has in their recovery.
So it, as you can imagine, I often run behind in clinic, but it's because I sit there and I make sure that the last question I ask them is, are there any more questions I can answer for you? Because I want them to know that we are a team, me and the patient, and that I give everybody my email so that they can contact me if they have any questions. It's amazing how few people, quote, bother me, but I encourage everybody to contact me anytime. But I think the starting, the fabric of a good doctor patient relationship needs to start at that first visit.
And we need to try to understand that we are not treating a shoulder, we're treating a patient. We're not treating a rotator cuff tear. We're treating a patient with a rotator cuff tear. And so often at meetings we hear about this is how I treat a massive irreparable cuff tear. But the real question we should be asking, recognize that most people with massive irreparable cuff tears are doing fine. I'm one of them. You know, I've got a massive irreparable cuff tear. It doesn't bother me a bit.
So if you want to treat me as a patient, you just pat me on the back and say, just keep doing what you're doing.
So maybe that's not the answer that you were seeking, but I think that to me, getting the understanding of what bothers the patient, making sure they know that you're going to be their teammate in addressing that, whether it's surgery or rehab or whatever.
And that I really enjoy those conversations because I learn a lot about them.
[00:27:38] Speaker B: Well, thanks for your contributions, Rick, and thanks for your spending time with us.
Always learning. I always learn from you and greatly appreciate it. Mo, what do you, what do you say?
[00:27:51] Speaker C: I just couldn't help but reflect on everything we've just heard and the conversation as well around. You know, in 1989, I'm here at McMaster University where, you know, Gordon Guide and David Sackett, you know, they coined the term evidence based medicine and they focused with one thing, patient centered care. And if this isn't a discussion about patient centered care, I don't know what is. So thank you again for this lovely gift of conversation. Rick and I can't believe that we won't be chatting again soon with your next interesting idea. So we'll be in touch soon, I'm sure. So thanks again for your time and thank you, Mark, for joining us with some great questions.
[00:28:29] Speaker D: It's been my real pleasure. And again, I have greatest admiration for both of you and for your huge contributions to our field and for keeping us focused on the right things. And Mark, I sometime I have to give you some feedback because my current fellow Jake Checketts is somebody that you championed when he was dealing with some interesting conflict of interest questions. And I think that that is one of our big issues.
We have to acknowledge it and just like we acknowledge the other things that we are imperfect about. But again, thank you so much for this morning and I hope you all have a wonderful day and stay cool.
[00:29:13] Speaker B: Let's take a trip to Seattle.
[00:29:15] Speaker D: Yeah, that's what we should do.
[00:29:18] Speaker C: Great. Thanks so much.
[00:29:19] Speaker D: Have a good day.
[00:29:21] Speaker B: Bye. Bye.
[00:29:21] Speaker D: Bye.
