Tuesday, September 9, 2014

Ream and run for posterior instability without glenoid retroversion

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.

Here's the assisted range of motion the morning after surgery

Comment: This case is interesting for a number of reasons. First, debridement seems rarely helpful in the management of substantial arthritis. Second, the pathology - posterior instability + arthritic head deformity -  only became apparent when a quality axillary radiograph was obtained. Third, the normal version of the glenoid did not provide stability (from this we may conclude that his posterior instability would not have responded to changes in glenoid version). Fourth, the anteriorly eccentric head and a rotator interval plication were required to stabilize the humeral head in the reamed glenoid.

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