Early recovery of motion after a ream and run for severe arthritic decentering

Here are the x-rays of a 40 year old with capsulorrhaphy arhtropathy.

His 'truth view' shows severe posterior decentering on a B2 glenoid.

He did not want to consider a bone graft or a plastic glenoid socket because of his active lifestyle and physically demanding job.

His post ream and run AP is shown here

and his post ream and run axillary here. Note the anteriorly eccentric humeral head. A rotator interval plication was also performed.

By 24 hours after surgery he had regained 140 degrees of assisted elevation.

On the second day, he showed this motion. Note the smooth assisted movement with no concern about posterior instability (video used with permission of the patient).

Here we are at one week.

A great early result, but lots of work left to do.

===

Consultation for those who live a distance away from Seattle.

Click here to see the new Shoulder Arthritis Book

Click here to see the new Rotator Cuff Book

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.

See the countries from which our readers come on this post.

Evaluating the arthritic shoulder without a CT scan using the 'truth' view.

A man in his mid 40s presented to us today with shoulder pain and limited motion.

his AP suggested mild to moderate arthritis.

However, the 'truth' view (a standardized axillary taken with the arm in the functional position of elevation in the plane of the scapula - see this link), revealed a retroverted, biconcave glenoid with posterior humeral decentering = the bad arthritic triad (BAT - see this link).

These two films provide the necessary information with which to discuss the possible surgical options and to plan the procedure.

===

Consultation for those who live a distance away from Seattle.

Click here to see the new Shoulder Arthritis Book.

Click here to see the new Rotator Cuff Book

Information about shoulder exercises can be found at this link.

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.

See the countries from which our readers come on this post.

More on the B2 glenoid

Earlier today, we posted on the assessment of glenoid pathoanatomy: see this link.

In the office today, we saw three of our patients in followup after arthroplasty for "B2" type posteriorly biconcave glenoids: two total shoulders and one ream and run. The preoperative and postoperative 'truth' views are shown below. Note that in each case the preoperative decentering was corrected even though there was no attempt to change glenoid version with anterior reaming, posterior bone graft or posteriorly augmented glenoid components.

===

Consultation for those who live a distance away from Seattle.

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.

See the countries from which our readers come on this post.

Posterior Augmented Glenoid - is there an advantage over the standard glenoid component?

Preliminary Results of a Posterior Augmented Glenoid Compared to an all Polyethylene Standard Glenoid in Anatomic Total Shoulder Arthroplasty

These authors report on 24 patients having total shoulder arthroplasty using a posteriorly augmented glenoid for arthritis with posterior glenoid wear. The degree of posterior wear and retroversion before surgery are not presented.

At two years after surgery, 60% of the shoulders had a periglenoid radiolucent line with an average radiographic line score of 1.10.

One glenoid was radiographically loose. 

Two shoulders demonstrated superior subluxation. 

Three were anteriorly subluxated.

Comment: These results speak to the challenges inherent in the use of posteriorly augmented components.

One of the rarely discussed concerns is the effects of using thick posterior polyethylene to manage the   posteriorly directed loads applied when the arm is elevated to the functional position of forward elevation, which is known to create the risk of functional decentering.

This is best explained by noting that when the arm is at the side with a posteriorly augmented glenoid, the net humeral joint reaction force (red arrow) is centered.

However, when the arm is elevated to a functional position, the net humeral joint reaction force (red arrow) is directed posteriorly against the posteriorly augmented polyethylene, subjecting it to the risk of cold flow.

 Furthermore, the point of application of the net humeral joint reaction force of the elevated arm creates an increased glenoid loosening moment (blue line), when the posterior polyethylene is thick.

It is possible that these mechanisms contributed to the development of lucent lines and instability with posteriorly augmented glenoid components in the series presented.


Our approach to the retroverted glenoid is simple - see this link..

(1) We do not rely on preoperative CT scans because they cannot image the shoulder in the functional  position of forward elevation. Instead we prefer the simple standardized axillary view taken with the arm elevated 90 degrees in the plane of the scapula as shown below (this shoulder demonstrates the bad arthritic triad).

(2) We do not use preoperative planning software or patient specific drill guides, but rather ream the glenoid conservatively without trying to 'normalize' glenoid version as shown in this link.

(3) Finally, in a total shoulder arthroplasty for a retroverted glenoid, we place a standard glenoid component on the conservatively reamed glenoid, using an anteriorly eccentric humeral humeral head component if necessary to achieve centering of the articulation. 

This type of reconstruction is shown below on an axillary view taken with the arm in the functional position of forward elevation. Note the centered humeral head and the lack of glenoid lucent lines after two years of implantation.

This approach perseveres the maximal amount of glenoid bone in contrast to what is required to fit the bone to a more complex back side geometry as explained in this link.

===

Consultation for those who live a distance away from Seattle.

Check out the new Shoulder Arthritis Book - click here.

Click here to see the new Rotator Cuff Book

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.

See the countries from which our readers come on this post.

Shoulder arthritis - evaluating and managing the abnormal anatomy

A comparison of normal and osteoarthritic humeral head size and morphology

These authors evaluated 150 humeral heads included: (a) "normal" cadaveric specimens, (b) patients with OA and  symmetric glenoid erosion, and (c) patients with OA and asymmetric (type B2) glenoid erosion.

Measurements included sphere-fit diameter of the humeral head articular surface, circle-fit diameter of the humeral head articular surface in the superoinferior plane, circle-fit diameter of the humeral articular surface in the anteroposterior plane, humeral head height relative to the osteotomy plane, and superoinferior and anteroposterior chord distances of the osteotomy surface after excision of the humeral head. Some of the results are shown in the chart below.

The authors concluded that while OA humeral head morphology varies significantly from normal, it does not vary between shoulders with symmetric and asymmetric glenoid wear. 

Comment: Essentially this study shows that arthritic humeral heads are flattened in comparison to cadaveric humeral heads without obvious arthritis. While the normal diameters of curvature ranged from 37 to 55 mm, the arthritic heads ranged in diameter from 36 to 96 mm in the AP dimension!

This humeral head flattening is nicely shown by a case we treated two years ago

 The standardized axillary view (the 'truth' view) also shows the biconcave glenoid and posterior subluxation of the head on the glenoid face (no CT needed).

While some surgeons may treat this pathology using patient specific instrumentation, posterior glenoid bone graft, reaming the high side of the glenoid or a posteriorly augmented plastic glenoid component, in these situations we ream the glenoid conservatively with out attempting to change version, insert a standard glenoid component, and balance the soft tissues. This shoulder was clinically and radiographically stable at two years after surgery.

On the standardized axillary view, the humeral head center remained nicely aligned with the center line of the glenoid prosthesis.

In our practice of ream and run arthroplasty, the glenoid is almost always reamed to a 58 mm diameter of curvature mating with a 56 mm diameter of curvature humeral head component irrespective of the preoperative pathoanatomy or the estimated 'normal' anatomy of the shoulder.

Be sure to visit "Ream and Run - the state of the art"  regarding this radically conservative approach to shoulder arthritis at this link.

===

Consultation for those who live a distance away from Seattle.

Click here to see the new Shoulder Arthritis Book

Click here to see the new Rotator Cuff Book

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.

See the countries from which our readers come on this post.

Ream and Run for the Bad Arthritic Triad - 6 year anniversary

Many of our ream and run patients are kind enough to provide us with annual reports of their ongoing progress. Here is the six year report from a man who had a ream and run for the Bad Arthritic Triad (biconcavity, retroversion and posterior subluxation)

Post op flims at 3 months

His function several years ago is shown as the last patient in this video

Here's the report on his 6th Year Anniversary

Well after six years, I still feel my shoulder is getting stronger every year.  I feel no “wear” or joint deterioration at all in my shoulder and do not expect any.  My shoulder is only 6 years old so why should I?  

Previously on anniversaries I have tried to target a new achievement I could pursue.  This year I decided target a couple of things I had already done in the past to see if I can do better now to support my claim that a “ream and run” shoulder should continue to get stronger if the patient is persistent in staying in shape.  So today I did 30 pull-ups and recently threw a football 35 yards.  That beats my old numbers of 25 pull-ups (last year) and 30 yards (4 years ago) so hopefully that will give your other patients hope that they too should expect their new shoulders to keep going and going.

Here was his 5th Year Anniversary update:

November 16, 2015 will mark the 5th anniversary of my “ream and run” surgery on my left shoulder. As a quick review, I am left-handed and for 15 years my shoulder got worse and worse with the last 10 years being so bad I could no longer do much of anything left handed. Even combing my hair required me to hold my left elbow with my right hand in order to direct my left arm. I was resigned to just keeping my left hand in my pocket most of the time.

During the 15 year period of my shoulder getting worse and worse, I did a lot of internet research and met with a handful of doctors. I had a couple of appointments to discuss shoulder replacement surgery. Technology may have improved but I was told while my range of motion would be greatly improved with full shoulder replacement surgery, sports were not recommended as the artificial joint connected to your Glenoid joint would eventually wear out and can potentially dislocate. When I mentioned I wanted to be able to do pull-ups, both doctors I met with remarked that the pull-up exercise was the number one movement to avoid (major concern about dislocation). Therefore to commemorate my 5th anniversary of “ream and run”, I did 25 pull-ups and then did 75 push-ups.

===

Check out the new Shoulder Arthritis Book - click here.

Click here to see the new Rotator Cuff Book

Consultation for those who live a distance away from Seattle.

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.

See the countries from which our readers come on this post.

Ream and run for the B2 glenoid - 4 year followup

The AP radiograph of this 50 year old man appears to show 'mild' arthritis. But he had an SST score of only 5 out of 12.

However, the 'truth' view, shows a posteriorly subluxated humeral head in bone on bone contact with. a biconcave B2 retroverted glenoid.

He elected a ream and run procedure because of his active lifestyle. At four years of active use of his shoulder, his x-rays are as shown below. The humeral head is nicely centered in a single glenoid concavity in both views.

There is no evidence of glenoid wear at four years after the procedure. At that followup his SST score  had improved from 5 out of 12 to 12 out of 12.

===

Consultation for those who live a distance away from Seattle.

Click here to see the new Shoulder Arthritis Book

Click here to see the new Rotator Cuff Book

To see the topics covered in this Blog, click here

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'