Sunday, July 28, 2013

Consultation via email for Ream and Run B2 glenoid. The 'one stop'.

We often receive email requests for consultation such as this (that I have paraphrased) from the Southeastern U.S (received yesterday).

I am 45 years old and have degenerative joint disease in my right shoulder. Experience occasional tingling, popping and grinding.  My shoulder was injured in a mountain biking accident with subsequent surgery to repair labrum. With resumption of activity, noticed reduced range, “popping” and “grinding” noises – worked through it for several years. Currently have stopped most upper-body exercises, focusing mainly on cardio and lower body. Recently shoulder has been “freezing” with a jolt of pain, then releasing. Livability of the problem has reduced significantly in the last 6 months. I have seen 2 Orthopedics in my area – one of them indicates that I am not a candidate for the ream and run procedure, while the other suggests that I am. In doing my own research I have discovered you and your fantastic blog. When I mentioned you to my doctors here, both encouraged me to contact you. Therefore, I am writing you to get your opinion on 2 questions:
1) Am I a candidate for the ream and run procedure? More specifically, do I have sufficient bone and tendon to permit the surgery?
2) If I am a candidate, your recommendation on the timing of the procedure. Do I risk further degeneration of the glenoid?

The axillary view below was enclosed in the eMail.

Regular readers of this Blog will recognize this as a B2 glenoid with posterior subluxation of the humeral head on a retroverted glenoid (for previous posts on this topic, enter "B2" in the 'search this blog' box to the right). 

This is, on one hand, perhaps the commonest pathoanatomy we encounter in young, active individuals with glenohumeral arthritis. On the other hand (as the prior blogs show) management of this condition requires highly specialized ream and run techniques to restore stability to the joint so that activities can be resumed. On average, the rehabilitation after a ream and run for this arthritic situation can be somewhat more difficult than with a type A glenoid, but we have many who have regained a high level of activity after a ream and run (usually with an eccentric humeral head and often with a rotator interval plication).  In our opinion a ream and run for the B2 is a vastly superior option in comparison to a total shoulder with a bone graft or in comparison to a reverse total shoulder, in that those approaches would substantially limit the type of activities that would be recommended after surgery.

As for the questions asked by the prospective patient:
(1) The bone stock of the glenoid is substantially compromised, but we have been able to successfully reconstruct many similar shoulders with the advanced ream and run techniques
(2) Degenerative arthritis is a progressive process. The rate of progression is highly variable among individuals, but the load concentration on the back of the glenoid and the posterior subluxation of the head on the glenoid all favor progressive posterior bone loss with time.

For such individuals we recognize that we cannot make a decision regarding surgery by email without seeing them in person. However, in this type of situation, we offer the possibility of a 'one stop' sequence in which we schedule surgery for a Tuesday and then see the patient on the preceding Monday for a complete evaluation. If all is 'go' for the surgery, we proceed. If the patient wishes to ponder the option longer or if there is a decision against surgery after discussion, we cancel the case for the Tuesday but keep the records on file for possible future re-activation.

A word of caution that we give to all those considering the 'one stop'. We do not proceed with surgery if the individual is not in the best possible health. This means dental hygiene is optimized before surgery, all medical issues are under optimal control, the fitness of the patient is good, and there are no problems with scratches, wounds, rashes or sores anywhere on the skin, including the axilla (arm pit). Sadly, we recently had to cancel surgery on a gentleman who flew all the way from Florida because of an abrasion on the elbow of the shoulder we'd planned for surgery. If there are any questions about any of these or other issues, we want to manage them before the patient gets on the airplane to fly here. 

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