Friday, October 20, 2017

Ream and run for posteriorly decentered humeral head on a biconcave glenoid

A bit over two years ago, we met a 53 year old author, radio and podcast host, fitness trainer, model, and international motivational speaker from California who presented with substantial pain and stiffness in his right shoulder. He could perform only 3 of the 12 functions of the Simple Shoulder Test. His preoperative x-rays are shown below.
 His axillary view shows a posteriorly decentered humeral head on a biconcave glenoid.
Because of his active lifestyle he elected the ream and run procedure. No CT scan, no polyethylene, no cement. We used a 56 18 humeral head, and 18 stem and performed a rotator interval plication to manage the shoulder's tendency for posterior  translation.

He sent us a video at 9 months after surgery (see this link) showing his ability to perform pull ups - something he'd been unable to do for 18 years before surgery.

At his two year followup, he reported the ability to perform all 12 of the Simple Shoulder Test questions, and "besides lifting weights again. I am back on a mountain bike with no pain. I compete in shotgun competitions (Trap). This means that in practice, I pull a trigger more than 600 times per week. That is 600 jolts to the "surgery shoulder" with no discomfort other than the normal shotgun related soreness. I can do 10+ pullups with no problem. I still do the flexibility exercises everyday and have continued to push the envelope there."

Yesterday he emailed, "Also, I'm planning a 100 mile kayak trip in Louisiana on the Bayou I grew up on, next spring. I'm attempting to do it non-stop. Thanks for completely changing my life. I was becoming fairly miserable to be around because of the constant pain. "

Once again, the patient's dedication to rehab makes the result!

Comment: The ream and run: not for every patient, every surgeon or every problem.

In a total shoulder arthroplasty, the humeral head prosthesis articulates with a polyethylene glenoid surface placed on the bone of the glenoid. Failure of the glenoid component is recognised as the principal cause of failure of total shoulder arthroplasty. By contrast, in the ream and run procedure, the humeral head prosthesis articulates directly with the glenoid, which has been conservatively reamed to provide a stabilising concavity and maximal glenohumeral contact area for load transfer. While no interpositional material is placed on the surface of the glenoid, animal studies have demonstrated that the reamed glenoid bone forms fibrocartilage, which is firmly fixed to the reamed bony surface. Glenohumeral motion is instituted on the day of surgery and continued daily after surgery to mold the regenerating glenoid fibrocartilage. When the healing process is complete - as indicated by a good and comfortable range of motion - exercises and activities are added progressively without concern for glenoid component failure.

The experience to date indicates that a technically well done ream and run procedure can restore high levels of comfort and function to carefully selected patients with osteoarthritis, capsulorrhaphy arthroplathy, and posttraumatic arthritis.

Patients considering the ream and run procedure should understand that this technique avoids the risks and limitations associated with a polyethylene glenoid component, but that it requires strong motivation to follow through on a rehabilitation course that may require many months. The outcome of this procedure depends on the body's regeneration of a new surface for the glenoid and requires rigorous adherence to a daily exercise program.
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Information about shoulder exercises can be found at this link.

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