Thursday, August 3, 2017

The ream and run for primary shoulder arthritis

Clinical and Radiographic Outcomes of the Ream-and-Run Procedure for Primary Glenohumeral Arthritis

These authors sought to evaluate factors associated with medialization of the humeral head after this procedure as well as the relationship of medialization to the clinical outcome. They collected patient, shoulder, and procedure characteristics along with Simple Shoulder Test (SST) scores before surgery and at the time of follow-up.

Two-year clinical outcomes were available for 101 patients (95% were male, mean age 60±9 years range, 35 to 80 years). Preoperatively, nearly half (49; 44%) had type-B2 glenoid morphology. The mean scapular body-glenoid angle was 69±12 degrees (range, 40 to 95 degrees) preoperatively (glenoid version is calculated as 90 degrees minus the scapular body-glenoid angle, thus the average glenoid retroversion was 21 degrees).

For all patients, the mean SST score increased from 4.9 ± 2.8 preoperatively to 10.3 ± 2.4 at the latest follow-up (p < 0.001):

Patients improved by an average of three-quarters of the maximum possible improvement in the SST score (the mean percentage of the maximum possible improvement [%MPI] achieved was 75% ± 34%)

The greatest clinical improvement was seen for shoulders with a type-A2 glenoid morphology, with larger preoperative scapular body-glenoid angles (i.e. less retroversion), and with lower preoperative SST scores. However, the procedure was effective in managing cases of type B2 glenoids with retroversion, glenoid biconcavity, and severe posterior decentering on the 'truth' view:

In this study, clinical outcome was not significantly affected by patient age, sex, ASA classification, smoking history, BMI, history of prior surgery, biceps status or details of the surgery (head diameter, head height, head eccentricity, use of rotator interval plication).

Medialization was determined by comparing the position of the humeral head prosthesis in relation to the scapula on postoperative baseline radiographs made within 6 weeks after surgery with that on comparable follow-up radiographs made ≥18 months after surgery.

Comparable radiographs at postoperative baseline and follow-up evaluations were available for 50 shoulders. Here is an example showing minimal (1 mm) medicalization at two years after surgery.
Here is a case showing above average (9 mm) of medicalization at 2 years after surgery.
 In these patients, the two-year clinical outcome was not significantly associated with the amount of medialization.

Fourteen shoulders underwent subsequent procedures. Four patients underwent closed manipulation under anesthesia for persistent stiffness. Seven patients underwent single-stage exchange of the humeral component and soft-tissue releases because of pain and stiffness; 6 of them had cultures positive for Propionibacterium at the time of revision. Three patients had revision to total shoulder arthroplasty (1 culture was positive for Propionibacterium, and 1 revision was performed at an outside institution without culture data available). Among the 50 patients with radiographic follow-up, the mean radiographic medialization was 1.8 ± 1.3 mm for the 2 who had revision compared with 2.4 ± 3.2 mm for the 48 who had not had revision (p = 0.6).

Comment: This study demonstrates that in an active (see the examples in this video), predominantly male population wishing to avoid the risks and limitations associated with a prosthetic glenoid component, the ream-and-run procedure was effective in improving shoulder comfort and function for osteoarthritic shoulders with a range of glenoid pathologies, including retroversion and type-B2 morphology. It also indicates that stiffness can be a substantial problem after this procedure. Medialization of the humeral head with respect to the glenoid can occur; while medialization did not affect two year clinical results, its long term clinical significance remains to be determined.

Additional commentary on this study can be found here.
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