Sunday, November 22, 2015

Ream and Run - state of the art

Due to the rapidly increasing interest world-wide in the ream and run procedure - the radically conservative approach to shoulder joint replacement for active individuals - we've assembled a readers' guide to all blog posts on this procedure. Just click on the underlined subject to open the link.


Ream and Run - research and development
Ream and Run for Shoulder Arthritis - Genesis

Considerations regarding the ream and run
The ream and run - a glenohumeral arthroplasty that avoids the risks of plastic glenoid components
Shoulder replacement for active people video 1
Shoulder replacement for active people video 2
The Ream and Run Essentials
Shoulder arthritis consultation for those who live away from Seattle
What is shoulder arthritis?
Shoulder arthritis - what you should know about it.
What are the types of shoulder arthritis?
How is the diagnosis of shoulder arthritis made?
The arthritic glenoid - evaluation and management
Is the shoulder arthritic or frozen?
Is the shoulder stiff?
Why do arthritic shoulders get stiff?
Assessing shoulder limitations - the Simple Shoulder Test
Shoulder limitations in Degenerative Joint Disease of the Shoulder
What can be done for shoulder arthritis without surgery?
When is it time for a shoulder replacement?
When is it the right time for a shoulder replacement for arthritis? Shoulder joint replacement - special considerations
A ream and run is not the same as a hemiarthroplasty
Patient factors that can influence the outcome of surgery
Considerations in treating shoulder arthritis in patients under 50 years of age
Shoulder arthritis - a vicious circle
Shoulder joint replacement for arthritis - when is the right time to have surgery? FAQ
The ream and run for shoulder arthritis - commonly asked questions - from a weight lifter
Shoulder Arthritis: The Cliff Notes for Physical Therapists and Other People
Shoulder joint replacement - many different types of arthritis
Can the glenoid be reamed after a biological resurfacing?
The ream and run and the kiss sign - the contribution of an intact labrum to the suction cup effect

X-ray Evaluation
Guide to shoulder x-rays for arthritis
Shoulder joint replacement arthroplasty - x-ray evaluation
The Axillary view = the 'truth' view
The axillary - truth - view. It tells us what we need to know about arthritis.
The Walch B2 glenoid in a young active person - a recurrent theme.Classifying glenoid morphology with axillary views and CT scans - comparable reliability
The Bad Arthritic Triad - BAT - the biconcave glenoid and its management
The relationship of glenoid version to stability in shoulder arthritis, the bad arthritic triad
Humeral subluxation in arthritic shoulders
Being physically active makes your body function more like a young person’s.
Patients taking narcotics before surgery often have poorer results from surgery
Medications and joint replacement

Factors affecting the outcome
Use of a ream and run to manage the bad arthritic triad without changing glenoid version.
Ream and run with RIP and eccentric head for a B1 glenoid seen on a standardized axillary view
Ream and run for the B2, retroverted glenoid
Ream and run for the posteriorly eroded type B2 glenoid with posterior humeral displacementReam and run with eccentric head and rotator interval plication for glenohumeral arthritis
Shoulder arthritis with posterior humeral subluxation managed with the ream and run
Glenoid reaming, why we don't use a guide wire
Ream and run for shoulder arthritis with a posteriorly subluxated humeral head
Humeral arthroplasty - does the entry point matter?
Ream and Run for Capsulorrhaphy Arthropathy - two recent cases
Ream and run for severe post fracture deformity
Managing a humeral shaft deformity with a stemmed humeral component
How we do a biceps tenodesis with shoulder arthroplasty?

Patient-specific instrumentation
Ream and run - patient observations at four years after the procedure for the bad arthritic triad
Extraordinary rehabilitation effort after a bilateral ream and run procedure
Antibiotics after joint replacement
Cartilage regrowth after the ream and run in an 81 year old farmer

Ream and run for the triad of biconcavity, retroversion and posterior humeral subluxation
Ream and run shoulder arthroplasty - results from Texas
Hockey after ream and run
Ream and run for B2 glenoid - back to active duty in our armed forces

Ream and run - will the glenoid wear away without a plastic glenoid component?
Ream and Run for the bad arthritic triad and B2 glenoid revealed by the truth view - two years later
A couple of two year followups after ream and run for advanced glenohumeral arthritis
Ream and run - two year followup.
Propionibacterium periprosthetic infections of hip, knee and shoulder


Check out the new Shoulder Arthritis Book - click here.

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and runreverse total shoulderCTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Ream and run - day one rehabilitation video

A patient in the mid 30's from the opposite coast presented to us with shoulder pain, stiffness, and limited function. He'd previously had a SLAP repair in 2009 and an open surgical debridement in 2010 without substantial change in his symptoms. He answered "no" to 7 of the 12 questions of the Simple Shoulder Test. He had essentially no motion at the glenohumeral joint. He brought in the x-ray he'd had 'back home' - it is shown below.

In clinic we repeated the AP view with a similar result

However as shown below, the axillary view (= the 'truth view') revealed severe posterior subluxation without any evidence of glenoid retroversion.

At surgery, the humeral head looked like this.

The resected head looked like this.

We performed a ream and run that included the use of an anteriorly eccentric head and a rotator interval plication. Here are his postoperative films.

His assisted range of motion the morning after surgery can be seen in this link.

Consultation for those who live a distance away from Seattle.

Click here to see the new Shoulder Arthritis Book

Click here to see the new Rotator Cuff Book

To see the topics covered in this Blog, click here

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and runreverse total shoulderCTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

This is not an apple

At the graduation, they presented me with a reproduction of a painting by René Magritte, Ceci n'est pas une pomme.

As the fellows recalled, we often use this painting to remind us that when we are looking at an x-ray, a CT scan or an MRI, we are not looking at the humerus, the glenoid or the rotator cuff. Rather we are looking at an image which incompletely and often inaccurately represents the object of interest. As in:

 Ceci n'est pas le sus-épineux

Saturday, November 21, 2015

Should I have a ream and run or total shoulder?

Should I have a ream and run or a total shoulder?

This is a question that confronts many patients with shoulder arthritis. In both procedures the arthritic ball (humeral head) is replaced with a smooth metal ball (humeral head) attached to a stem that is fitted down the inside of the arm bone (shown below).

The difference in the two procedures is the way in which the glenoid socket side of the joint is managed.

In a total shoulder, the surface of the glenoid bone is covered with a plastic implant that fits the metal humeral head component and that is fixed to the bone beneath it by fluted pegs and a small amount of bone cement. This immediately gives the humeral head a smooth surface to move on – no healing of the surface is required. While range of motion exercises are necessary to achieve and maintain the shoulder’s range of motion, these exercises are not needed to shape the socket. After this procedure it is recommended that the patient avoid impact loading (e.g. chopping wood) and weight workouts (e.g. bench press) to minimize the risk of wear and loosening of the plastic glenoid component.

In the ream and run, the bone of the glenoid socket is reamed to a concavity that fits the metal humeral head component.

Persistent five times daily stretching exercises are necessary to stimulate the reamed surface (below left) to heal over with a layer of fibrocartilage (below right).

At the time of surgery, we assure that the shoulder is stable and capable of an excellent range of motion. However, each person’s healing response is different - some shoulders want to tighten up due to their body's vigorous healing response. As a result the amount of time required for healing varies, but seems to be largely dependent on the daily dedication of the patient to the simple, but critical exercise program. The most successful patients keep a calendar and check off each of their five daily exercise sessions – bringing the calendar to the office for their follow-up visit.

In many cases this healing process is well under way by 6 months after surgery, but in some cases it can take a year or longer. For some individuals these exercises seem easy, while others find them uncomfortable and at times frustrating. The key is to achieve over 150 degrees of elevation of the arm by 6 weeks after surgery and to maintain it. If this goal is not achieved by six weeks, we recommend an outpatient manipulation of the shoulder under anesthesia and muscle relaxation. When rehabilitation is complete, the patient can progressively return to use of the arm as the comfort of the shoulder allows. In this procedure there is not a need for limiting activity to minimize the risk of failure of a plastic implant. In some instances the pain relief with the ream and run is not as complete as with a total shoulder, however in many cases the pain relief is excellent.

Both the total shoulder and the ream and run procedures carry a small, but definite risk of infection from the bacteria that grow on the patient's skin. This risk is higher in male patients and in those shoulders having had prior surgical procedures.

The average patient with shoulder arthritis prefers a total shoulder because for most individuals it gives the best and most rapid relief of pain without a very demanding rehabilitation program. Individuals having this procedure can often return to swimming and golf.  The ream and run is attractive to those individuals who want to return to high levels of activity involving impact and major loads without having to be concerned about wear or loosening of the plastic glenoid socket. While it is a real joy to see patients achieve high levels of function after the ream and run, it is saddening to see some patients struggling with their exercise program. Thus, if the patient is unsure about their ability to stay motivated and dedicated to the rehabilitation program, we counsel the patient to have a total shoulder. The question comes down to how much the patient is willing to dedicate to a possibly difficult, five times daily rehabilitation exercises in exchange for avoiding the potential limitations in activity needed to protect the plastic socket. Often we get a question like "I desire to restore a more normal movement of my shoulder, reduce or eliminate pain and be able to keep riding my off-road motorcycles through the many trails in the Southeast US.   Could the R&R procedure accomplish these goals for me?" The answer is, "no' the ream and run cannot accomplish these goals by itself, but a solid rehabilitation effort after a ream and run procedure can often lead to great shoulder function and improved comfort. In considering this procedure, be sure to read the posts entitled "ream and run: rehabilitation tips from the superstars" to get an idea of the level of commitment.

See this link to the Ream and Run - State of the Art

Shoulder arthroplasty - consideration of varus and valgus head position

Total Shoulder Arthroplasty Outcome for Treatment of Osteoarthritis: A Multicenter Study Using a Contemporary Implant.

These authors present their results of primary total shoulder arthroplasty for osteoarthritis using an implant that provides dual eccentricity and variable neck and version angles for reconstruction of proximal humeral anatomy using a replicator plate interposed between the head and stem.

This design enabled the surgeon to vary the angle of the head on the stem by 15 degrees.

At a mean follow-up of 3 years (minimum, 2 years), they had an 81% follow-up rate of 218 total shoulders. Range of motion and clinical outcomes were significantly improved at final follow-up. 

There were 32 complications in 25 shoulders. Seven shoulders had multiple complications. The most common postoperative complication was rotator cuff failure (13 shoulders, including 8 treated with revision arthroplasty). The second most common complication was infection (6 shoulders, 1 with a superficial suture abscess and 5 with deep infections). Other complications were instability (4, with 2 caused by rotator cuff insufficiency), glenoid loosening (4, with 2 caused by infection), stiffness (3), nerve issue (1), and hematoma evacuation (1).

In 21 shoulders, these complications were treated with revision shoulder arthroplasty (16 shoulders), arthroscopic capsular release (3), evacuation of postoperative hematoma (1), and débridement of suture abscess (1). The 16 revision shoulder arthroplasties performed were conversion to reverse shoulder arthroplasty (11 shoulders) and placement of an antibiotic spacer for infection (5).

Comment: There is substantial variability in the anatomy of the arthritic humerus; the 'anatomic' location of the previously normal articular surface is difficult to determine.

While a number of implant systems allow variability in the inclination of the head, the effect on the center of rotation of the articular surface seems small.
We use a simpler approach of placing the humeral head at an angle of 45 degrees with the medullary axis of the shaft in all cases, irrespective of the appearance of the preoperative pathoanatomy.






The only variability in head position that we've found useful is anterior or posterior eccentricity to optimize  intraoperative stability (see this link).


The use of the eccentric humeral head does not require an interposed replicator plate.

Check out the new Shoulder Arthritis Book - click here.

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and runreverse total shoulderCTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Friday, November 20, 2015

Shoulder arthroplasty components and jet fighters

This week in clinic we were visited by an implant representative who was advocating a shoulder implant system that had a large modular ingrowth stem, a metal backed glenoid with a large central peg.

This 'heavy metal' approach is in marked contrast to the lighter, more flexible approach that we use as shown in one of this week's cases

The discussion between heavy and rigid on one hand and light and maneuverable on the other hand reminds us of the discussion between the proponents of the 63 ft long, 29,535 pound empty weight F-4 Phantom 

and the 49 ft long, 18,900 pound empty weight F-16 Fighting Falcon.

For a riveting discussion of the value of the light and maneuverable, every shoulder surgeon must read the book: Boyd: The Fighter Pilot Who Changed the Art of War.  This transformative biography was called to my attention by Seth Leopold, editor of Clinical Orthopaedics and Related Research.


Check out the new Shoulder Arthritis Book - click here.

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and runreverse total shoulderCTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'