Saturday, March 29, 2014

The ream and run arthroplasty for shoulder arthritis - commonly asked questions - this time from a weight lifter

We get many questions form individuals interested in learning more about the ream and run procedure

Yesterday we received from questions from an avid weight lifter. We've paraphrased the questions and the responses below.

"I have been a very heavy weightlifter and now find myself with two arthritic shoulders at age 42.  The right has a torn labrum and subluxed biceps tendon,  but the left is further along in the arthritis and really probably replacement  level already.  The humeral head is flattened and the glenoid has "subchondral signal heterogeneity."  However, I have little pain if I don't lift.  Lifting,  though, is a way of life for me and almost impossible to give up, so while I have dramatically adjusted my routine, I still lift and sometimes lift heavy.  A few times a month I will still bench press with 315, for instance (and really, I'm not super happy with that number).  The knowledge that I will need at least one and probably two arthroplasties haunts me, as I know that after that I'll be able to do very little upper body work without risking destruction of the prosthetic glenoid and revision surgery."

Question: What are the limitations after a ream and run?  Could I bench with 400 and do standing military presses with 225?  I would take less than this (I'd take  what I can get), but it would be nice to know the true limits, if there are any.

Answer: Patients have been able to return to weight lifting and other strenuous activities after the ream and run, but the results each individual achieves depends on may factors - we describe them as the '4 Ps'.
The first "P" is the problem - what is the condition of the shoulder, including the glenohumeral pathoanatomy, type of arthritis, bone quality, the rotator cuff, prior surgeries, injections, etc
The second "P" is the patient - age, gender, physical health, mental heath, motivation, willingness to adhere to the rehabilitation program, medications, social support, and expectations. The ream and run is not for most patients with shoulder arthritis.
The third "P" is the procedure - the ream and run is a technically difficult procedure that needs to optimize motion, stability, bone preservation, and  load transfer at the glenohumeral joint. It is not for many patients and is not for many surgeons.
The fourth "P" is the physician performing the procedure - the ream and run requires not only expertise with shoulder surgery in general, but also specific experience with the essential technical details. 
After the ream and run rehabilitation is completed, we advise the patient to progressively increase their shoulder activities as comfort allows, making sure that any exercise can be repeated comfortably 20 times and that exercises that risk the rotator cuff are avoided.

Question: I understand that fibrocartilage forms over the glenoid.  Isn't this less elastic than hyaline?  Is it really sufficient to cushion the bones under heavy loads, or will it wear away eventually?  Or are we hoping they in rehab I can build up enough shoulder muscle to help with the cushioning?

Answer: Fibrocartilage is not the same as hyaline cartilage, but it resembles it more that the alternative: plastic. Wear has not proved to be an issue after the ream and run.

Question:  Isn't removal of bone stock in the reaming process a concern?  If fibrocartilage does wear away, how screwed am I?  Do I go to a total shoulder then?  Can I?

Answer: The reaming in a ream and run procedure is very conservative. The amount of bone removed is less that what is removed in a total shoulder. It is possible to revised a ream and run to a total shoulder, however, the need to do this has been very rare in our experience.

Question: To the end of evaluating the prior questions, what are the longest follow ups you have?  Are there examples that suggest this could last me over 20 years?  Is it possible for me to look at any studies on longevity of the procedure?

Answer: We first started doing the ream and run as a salvage for failed glenoid components after total shoulder arthroplasty. This was in the mid 1990s. The successful results in some of these cases led us to start doing the ream and run as a primary procedure for carefully selected patients with osteoarthritis. The results of a major followup study are shown here.

Question: No one recommends a shoulder replacement before I am in a lot more pain than now.  Do you agree?  Is there any merit to doing a ream and run now,  before any further degeneration?

Answer: The timing of surgery for any type of shoulder arthroplasty depends on my factors, including the degree of loss of comfort and function as well as the degree of destruction of the glenoid bone

Question: What do you think about Autologous Chondrocyte Implantation as an  alternative?  It doesn't seem to have been tried much in shoulders, but I have  heard at least one success story.  It seems to me like a long road, since I  think I'd still need the humeral head replaced and osteophytes to be shaved down to avoid destroying any new cartilage we did manage to implant.

Answer: ACI is used for small areas of cartilage loss, not osteoarthritis. 

Question: Is there any hope of better prosthetic glenoid materials in the near future?  This seems like the obvious path for research, and it is frustrating never to hear anything about it.

Answer: The issue with prosthetic glenoid components is largely the issue of its fixation to bone. Newer approaches have not solved this issue. The glenoid component remains the weak link of total shoulder arthroplasty.


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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'