Should I have a ream and run or a total shoulder?
This is a question that confronts many patients with shoulder arthritis. In both procedures the arthritic ball (humeral head) is replaced with a smooth metal ball (humeral head) attached to a stem that is fitted down the inside of the arm bone (shown below).
The difference in the two procedures is the way in which the glenoid socket side of the joint is managed.
In a total shoulder, the surface of the glenoid bone is covered with a plastic implant that fits the metal humeral head component and that is fixed to the bone beneath it by fluted pegs and a small amount of bone cement. This immediately gives the humeral head a smooth surface to move on – no healing of the surface is required. While range of motion exercises are necessary to achieve and maintain the shoulder’s range of motion, these exercises are not needed to shape the socket. After this procedure it is recommended that the patient avoid impact loading (e.g. chopping wood) and weight workouts (e.g. bench press) to minimize the risk of wear and loosening of the plastic glenoid component.
In the ream and run, the bone of the glenoid socket is reamed to a concavity that fits the metal humeral head component.
Persistent five times daily stretching exercises are necessary to stimulate the reamed surface (below left) to heal over with a layer of fibrocartilage (below right).
At the time of surgery, we assure that the shoulder is stable and capable of an excellent range of motion. However, each person’s healing response is different - some shoulders want to tighten up due to their body's vigorous healing response. As a result the amount of time required for healing varies, but seems to be largely dependent on the daily dedication of the patient to the simple, but critical exercise program. The most successful patients keep a calendar and check off each of their five daily exercise sessions – bringing the calendar to the office for their follow-up visit.
In many cases this healing process is well under way by 6 months after surgery, but in some cases it can take a year or longer. For some individuals these exercises seem easy, while others find them uncomfortable and at times frustrating. The key is to achieve over 150 degrees of elevation of the arm by 6 weeks after surgery and to maintain it. If this goal is not achieved by six weeks, we recommend an outpatient manipulation of the shoulder under anesthesia and muscle relaxation. When rehabilitation is complete, the patient can progressively return to use of the arm as the comfort of the shoulder allows. In this procedure there is not a need for limiting activity to minimize the risk of failure of a plastic implant. In some instances the pain relief with the ream and run is not as complete as with a total shoulder, however in many cases the pain relief is excellent.
Both the total shoulder and the ream and run procedures carry a small, but definite risk of infection from the bacteria that grow on the patient's skin. This risk is higher in male patients and in those shoulders having had prior surgical procedures.
The average patient with shoulder arthritis prefers a total shoulder because for most individuals it gives the best and most rapid relief of pain without a very demanding rehabilitation program. Individuals having this procedure can often return to swimming and golf. The ream and run is attractive to those individuals who want to return to high levels of activity involving impact and major loads without having to be concerned about wear or loosening of the plastic glenoid socket. While it is a real joy to see patients achieve high levels of function after the ream and run, it is saddening to see some patients struggling with their exercise program. Thus, if the patient is unsure about their ability to stay motivated and dedicated to the rehabilitation program, we counsel the patient to have a total shoulder. The question comes down to how much the patient is willing to dedicate to a possibly difficult, five times daily rehabilitation exercises in exchange for avoiding the potential limitations in activity needed to protect the plastic socket. Often we get a question like "I desire to restore a more normal movement of my shoulder, reduce or eliminate pain and be able to keep riding my off-road motorcycles through the many trails in the Southeast US. Could the R&R procedure accomplish these goals for me?" The answer is, "no' the ream and run cannot accomplish these goals by itself, but a solid rehabilitation effort after a ream and run procedure can often lead to great shoulder function and improved comfort. In considering this procedure, be sure to read the posts entitled "ream and run: rehabilitation tips from the superstars" to get an idea of the level of commitment.
Be sure to visit "Ream and Run - the state of the art" regarding this radically conservative approach to shoulder arthritis at this link.
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