Saturday, November 9, 2013

The ream and run - a glenohumeral arthroplasty that avoids the risks of plastic glenoid components

Ream and Run
1. Description - The ream and run procedure is a glenohumeral arthroplasty that combines a humeral hemiarthroplasty with concentric reaming of the glenoid bone without the use of a prosthetic glenoid component or polymethylmethacrylate. A ream and run is not the same as a hemiarthroplasty, as explained here. It is a non-prosthetic method for managing arthritis of the glenoid socket (Matsen 2007 JSES ). Some of the essentials of the procedure can be seen here. Information on the basic research behind the ream and run can be found here. We have had the opportunity to perform over 400 of these surgeries, which has given us the opportunity to refine our patient selection and technique.

2. Indications - – The ream and run is offered to individuals who desire active use of their shoulder arthroplasty without concern for failure of the glenoid component. This procedure is used for primary and secondary osteoarthritis, posttraumatic arthritis and capsulorrhaphy arthropathy. It is avoided in inflammatory arthritis because of the softness of the glenoid bone and in glenoid dysplasia because of inadequate glenoid bone stock. Candidates for this procedure understand that a diligent, persistent and prolonged rehabilitation effort may be required to avoid stiffness after this procedure. Individuals who smoke, use substantial narcotic medications, or who have major physical or mental health concerns are not good candidates for this procedure.

3. Technique - a step by step approach to the ream and run is shown here. The JBJS has published a recent version of the technique here. The Video Journal of Orthopaedics has provided a short view of the technique.

Information about the use of eccentric humeral head components to optimize glenohumeral stability can be found here.

A discussion of special considerations for different types of arthritis can be found at this link.

A discussion of factors informing the selection of the humeral component is included in this link and in this link

Here is our method for the initial preparation of the humerus - see this link.

Here is our method for inserting the humeral component - see this link.

Our surgical technique, step by step:
The exposure and the humeral side of the arthroplasty
4. Rehabilitation - The most important aspect of the post operative rehab program is preventing stiffness - using the exercises shown here. For this reason we usually use continuous passive motion immediately after surgery. Some patients have developed creative approaches to their rehab as shown here. Here is the voice of experience. A good early effort is key to the success of this procedure. In this post, a patient shows exactly how the rehabilitation should be done.

And see the rehabilitation tips from the ream and run superstars, starting with the post linked here.

5. Results - A technically well done ream and run followed by a dedicated rehabilitation effort on the part of the patient usually yields a substantial improvement in shoulder comfort and function, enabling the patient to return to activities without surgeon-imposed limitation and without concern for failure of a plastic glenoid socket replacement. Younger patients, those with multiple prior surgeries, those with complex pathoanatomy, those with extremely poor function prior to surgery, those taking major pain medication, and those who have difficulty maintaining a consistent rehabilitation effort may have greater difficulty in achieving the desired result. Some of the clinical results have been published in peer-reviewed orthopaedic journals as shown below:
   Ream and run for the shoulder arthritic triad (Matsen 2014)
   Effect on glenohumeral pathoanatomy (Matsen 2013 CORR)
   Improvement in shoulder comfort and function (Gilmer 2012 JBJS)
   Results in patients 55 years old or less (Saltzman 2011 JSES)
   Results of the ream and run in comparison to total shoulder (Clinton 2007 JSES)
   Patient self-assessed outcomes (Lynch 2007 JBJS)
   Here is a video showing the level of function achieved by some of the patients having a ream and run.

Much more information on the results of ream and run can be found here,  Also see these videos sent in by patients: DrummingChopping woodRacquetballLifting weights and racquet sportsWaterskiingPlaying violinPassing the football, sinking three pointers, doing hand standsThrowing batting practiceHitting the body bag

The recovery after a ream and run is progressive over the years as shown here and here.

6. Complications - the possible risks of the ream and run procedure include stiffness, pain, and infection. If stiffness and pain are persistent at six weeks after surgery, a gentle manipulation under anesthesia with complete muscle relaxation is often helpful. If stiffness is present months after the procedure, a surgical soft tissue release is an option. Infection is uncommon after this procedure, especially if advanced prophylactic antibiotics (Ceftriaxone and Vancomycin) are used before and for a day after surgery. Fractures are extremely rare with the impaction bone grafting technique.

Here is some updated information on our experience with the ream and run.

Here are some commonly asked questions from patients about the procedure.

Consultation for those who live a distance away from Seattle.

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