Wednesday, April 2, 2014

Ream and run - two year followup.

Here are the radiographs of a 68 year old person from north of here. 

At that time when he presented to us two years ago, he could perform none of the 12 functions of the Simple Shoulder Test with his right arm.

Because of his desire to return to heavy use of his arm he desired a ream and run procedure.

Here is his operative note:

Degenerative joint disease right shoulder.
Right shoulder hemiarthroplasty with nonprosthetic glenoid arthroplasty.
Mr. _. is a patient with severe pain and loss of function of the right shoulder because of degenerative joint disease. Knowing in detail the alternatives as well as the risks of infection, neurovascular injury, stiffness, pain, weakness, fracture, component loosening, instability, glenoid arthritis, anesthetic complications and the need for revision surgery, the patient desires to proceed with the above-described procedure.
There was a total loss of articular cartilage over the humeral head and glenoid. The rotator cuff was intact. The quality of the bone was excellent. The structure of the humeral head and glenoid was distorted by the arthritis. There were degenerative cysts in the humeral head.
Ceftriaxone and Vancomycin were administered IV on time and will be discontinued at 24 hours. Antibiotic-containing irrigation fluid was used throughout this case.
Under satisfactory anesthesia, the shoulder was doubly prepped and draped in the usual manner. The shoulder was approached through a long anterior deltopectoral incision. The skin knife was discarded after the skin incision. The abundant scar in the humeroscapular motion interface was lysed.
The subscapularis was carefully incised from its insertion to the lesser tuberosity along with the subjacent capsule. The humerus was exposed by gentle external rotation. The medullary canal was entered and gently reamed to 12 mm. The humerus was prepared to receive the definitive humeral component, which was the 12 56 21 eccentric anterior to help manage posterior instability. This was assembled on the back table. All marginal osteophytes were excised.
Attention was then directed to the glenoid where a very careful iterative glenoid reaming was performed with a 56+2 glenoid reamer according to the establish University of Washington technique. The labrum was carefully preserved. Excellent contouring of the glenoid surface was achieved.
The wound was thoroughly irrigated. The humerus was treated with impaction autografting using bone harvested from the resected humeral head. Drill holes were placed at the anterior neck cut for reattachment of the subscapularis.
The definitive humeral prosthesis was inserted into the medullary canal paying careful attention to its register with respect to the reamed glenoid. A rotator interval plication was required to further provide posterior stability. A stable articulation was achieved.
The subscapularis was securely repaired to the sutures previously placed at the humeral neck cut. The wound was thoroughly irrigated and closed in layers. Dry sterile dressings were applied.
External rotation at the OR table with the subscapularis attached was to 45
The patient was returned to the recovery room in satisfactory condition with his arm in continuous passive motion. Our postoperative plan calls for continuous passive motion in the recovery room and on the floor and for the 150-degree assisted elevation program to be started today.

At his two year post-surgical followup he was performing all 12 of the Simple Shoulder Test functions.
His two year followup radiographs are shown here. Note the radiographic joint space and the use of the anteriorly eccentric humeral head as well as the absence of cement or plastic and the secure fixation of the humeral stem achieved by impaction grafting.

He is back to unrestricted use of his arm with a stable shoulder and a stable non-prosthetic glenoid arthroplasty.

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