Thursday, July 2, 2015

Ream and run shoulder arthroplasty - results from Texas

Self-assessed and radiographic outcomes of humeral head replacement with nonprosthetic glenoid arthroplasty.

These authors report on the results of the ream and run procedure in 21 shoulders (20 patients) of which 17 patients were available for a minimum of two-years followup (median 4.3 years range, 2.0-6.8 years). 11 shoulders were in males and 6 were in females. Mean age 55 years (range 24-69).  Prior surgeries were reported in 8 of 17 shoulders, including rotator cuff repair in 2, stabilization procedures in 2, arthroscopic debridement in 1, unknown open surgery in 1, and multiple procedures in 2. The procedure was offered to patients with glenohumeral arthritis and with activity expectations that included work or sports involving impact, heavy lifting, or strenuous use of the upper extremity as well as those who had requested surgical intervention but did not wish to undergo a total shoulder for various reasons. Before surgery patients were informed of the potential for both longer recovery time and functional outcome less than that expected for total shoulder arthroplasty.

The surgical technique sought to preserve all stable labral tissue to optimize its contribution to stability and load bearing. The size of the glenoid reamer was selected using a set of translucent, convex-backed glenoid sizing disks seeking to minimize damage to the surrounding labral tissue. Importantly, nubbed reamers were used without a central guide wire, fashioning a smooth concavity  at a diameter 2 mm larger than the prosthetic humeral head.  Priority was given to preservation of glenoid bone stock rather than to correction of anatomic version.  Soft tissue balancing was performed with attention to previously described criteria: (1) posterior drawer testing with 40% to 60% posterior translation of the humeral head relative to the center of the glenoid, (2) 75 of internal rotation with the arm positioned in 90 of abduction, (3) ability to place the hand on the superior aspect of the contralateral shoulder without scapula protraction, and (4) 45 of external rotation with the subscapularis approximated to the proximal humeral osteotomy site. A routine biceps tenotomy was performed. Passive range of motion exercises were started on the day of surgery.

The shoulders' Simple Shoulder Test score improved from mean 3.2 ± 3.1 preoperatively to 10.0 ± 2.6 at latest follow-up (P < .0001). American Shoulder and Elbow Surgeons score improved from mean 42 ± 23 to 90 ± 13 (P < .0001). Male patients had higher SST scores (P = .03) and greater external rotation (P = .03) at latest follow-up. Importantly, they found that shoulders with concentric glenoid morphology preoperatively did not demonstrate results superior to those of patients with eccentric glenoids.

One 54-year-old male patient had good function and relief of pain (SST, 11; ASES, 100) until  a high-speed automobile collision 3.5 years after surgery;  he was revised to a TSA at 4 years postoperatively. One female patient was revised to a TSA because of residual pain despite improvements in comfort, function, and range of motion (SST, 7; ASES, 70.5). The other patient required conversion to a reverse  TSA because of gradual decline in function and comfort secondary to instability (SST, 3; ASES, 65).

Comment: This study used an approach to the ream and run procedure similar to that we've described previously - our technique is described in some detail in this post.  A few differences may be worth noting: (1) we do not perform a routine biceps tenodesis and (2) we try to use a 58 mm diameter of curvature reamer and a 56 mm diameter of curvature humeral head for almost all patients.

The results achieved in this study are superior to those we achieved with our first patients back in the 1990s - these authors are to be congratulated on their more rapid ascent of the learning curve. We again suggest that this procedure is not for every patient, every surgeon or every shoulder pathology; however in carefully selected cases it offers an opportunity to return to full function without the risk of glenoid component failure. Over time, we've learned what it takes to get a super result from this procedure.


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