Ream and run to salvage failed hemicap.

 A 35 year old physically active patient presented with a history of 6 prior surgical procedures culminating in a hemicap. Since that operation the shoulder was extremely stiff and painful. X-rays in the clinic showed a hemicap that had eroded into the glenoid bone.

The patient desired a revision to a ream and run performed under general anesthesia without a nerve block.  Surgical findings included a tightly contracted capsule and subscapularis, a medially eroded glenoid, several suture anchors on the face of the glenoid, no synovitis, a frozen section showing no neutrophils, and a well fixed humeral component.

The glenoid was reamed to a diameter of curvature of 54 mm, and a canal sparing stemmed implant was inserted with a 48 15 humeral head. Because of the history of multiple prior surgeries and the glenoid erosion, the patient was placed on the red protocol. The postoperative films are shown below.

Four hours after surgery the patient had this range of motion.

The patient was discharged home on the first post op day on mild analgesics.

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Is humeral resurfacing a conservative treatment for primary arthritis?

Outcome and revision rate of uncemented glenohumeral resurfacing (C.A.P.) after 5–8 years

These authors report the mid-term results of an uncemented resurfacing shoulder prosthesis in patients with primary osteoarthritis having surgery from January 2007 to December 2009. No glenoid arthroplasty was used in these patients.

Forty-six patients (12 males) with a mean age of 72 years old (range 59–89) were included. At a mean 6.4-year follow-up (range 5–8), the Constant Score, visual analog pain scale and the Dutch Simple Shoulder Test scores improved significantly (p < 0.05) from baseline.

 Eleven patients (23%) had a revision operation.

They compared their revision rate to that in prior publications

Comment: We're often asked whether a resurfacing hemiarthroplasty is a conservative option for the management of glenohumeral arthritis. As demonstrated by this study, the issue with the resurfacing hemiarthroplasty appears to be the fact that it does not address the glenoid aspect of glenohumeral arthritis. These authors did not seem to have problems with fixation of the humeral component, but rather most of the problems related to glenoid erosion.

While it may seem simple to combine a resurfacing with a glenoid component, experience has shown that the retention of the humeral anatomic neck can interfere with good access to the glenoid, compromising the ability to perform a technically excellent prosthetic glenoid arthroplasty.

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Healing through joint replacement

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Is there an advantage in partial humeral resurfacing hemicaps?

The hemicap was designed as a partial humeral head resurfacing that removes a minimal amount of bone. Here is the AP x-ray of the right shoulder of an active man taken two years ago.

He was treated with a hemicap at another institution. 

Because of pain and a sensation of crepitance, he presented to our service. Physical examination revealed a limited range of motion with a grinding that was palpable. His x-ray at presentation to us is shown below, demonstrating contact between the unresurfaced portion of the arthritic humeral head and the glenoid.

This finding was verified at surgery as shown below - note the prominent bone beneath the hemicap.

This was revised to a traditional hemiarthroplasty, which replaced the arthritic humeral joint surface with a smooth prosthetic humeral head secured by an impaction grafted stem in the medullary canal. No glenoid arthroplasty was required. The postoperative x-rays are shown below.

Immediately after surgery the shoulder demonstrated improved range of motion without crepitance.

Comment: A smaller implant is not necessarily more conservative. The structural properties of the metal hemicap are quite different from the neighboring bone. Incomplete resurfacing of the humeral articular surface risks contact between arthritic humeral bone and the glenoid.

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Failed resurfacing revised to an impaction grafted hemiarthroplasty.

A gentleman in his sixties presented to us  7 months status post a left shoulder resurfacing with a hemicap. He states that he has continued to have moderate to severe pain and stiffness in his shoulder that is worse than preop. He has been to 30-40 PT sessions without relief. He noted that his shoulder 'clicked' painfully on certain motion.

His x-rays at the time of his initial clinic visit are shown below. There is a suggestion of incomplete seating of the hemicap, lucency around the central peg, and varus positioning.

He desired revision arthroplasty. Specimens for culture were obtained before antibiotic administration. The resurfacing prosthesis was grossly loose and the bone beneath it very soft. A hemiarthroplasty was inserted using Vancomycin allograft. He is on the yellow protocol pending the results of culture.

Comment: While we do not use the resurfacing prosthesis in our practice, we have had the chance to revise a fair number of these procedures performed elsewhere. Those coming for revision have had problems of malposition, overstuffing, loosening, infection and stiffness.

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Can the glenoid be reamed after a biological resurfacing? Hemicap. Copeland. Ream and Run.

This email came in yesterday: "I had a hemiarthroplasty of my shoulder last February with a hemicap and the glenoid was biological resurfaced. Unfortunately my shoulder, at times, is still in significant amount of pain and stiff. My questions are: Is it possible to have the glenoid reamed after a biological resurfacing? Also, can the procedure be done with a hemicap or does the humeral head have to have a spherical resurfacing like a copeland?"

First, a few illustrations to clarify the situation. 

Here is an x-ray of a hemicap from the manufacturer's brochure. Note that only part of the humeral joint surface is covered, in this illustration the joint space is not congruent, and the inferior humeral osteophyte appears to be contacting the inferior glenoid.

Here is a photo from an article on biological resurfacing in which a lateral meniscus was sutured around the periphery of the glenoid.

Here is an illustration of the Copeland shoulder.

Here is an x-ray after a ream and run procedure, in which the glenoid has been reamed to match the curvature of the new humeral head which is fixed without cement in the shaft of the humerus. The only bone that is removed in this procedure is that of the arthritic humeral head. The bone removed is used to help achieve a tight fit of the stem in the humeral shaft. Note the dark space between the humeral head and the glenoid where a new soft tissue layer has regenerated.

In answer to the question posed in the email, yes we have been able to ream the glenoid in cases of failed resurfacing. In these cases we routinely obtain cultures in that there seems to be a rather high rate of culture positivity for Propionibacterium in failed arthroplasties. In fact, here is a post of such a case after a Copeland arthroplasty.

In the ream and run procedure, we use a stemmed humeral component as shown in the x-ray above because it gives maximal security of fixation and maximal flexibility of head size, curvature, and position.

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humeral head resurfacing arthroplasty and humeral hemiarthroplasty in cadavers - JBJS Jan 2012

Hammond et al performed a seven cadaver study comparing humeral head resurfacing and hemiarthroplasty.

The authors disclose that this study was funded by a grant from Arthrosurface (which was the resurfacing prosthesis used in this study) and that one of the authors has a consultancy arrangement with Arthrex (which markets this prosthesis).

The model was of a normal shoulder, not of a shoulder with any of the types of conditions for which shoulder arthroplasty is performed. In contrast to the clinical situation where shoulder joint replacement is indicated, the glenoid anatomy was normal.

The resurfacing technique involved reaming away the surface of the normal humeral head around a guidewire and then placing a resurfacing cap over the guidewire. In this procedure the humeral head is not removed. When approaching a patient with shoulder arthritis, both sides of the joint (the humeral head and the glenoid) are almost always involved. Retaining the humeral head severely compromises access to the glenoid making the glenoid arthroplasty (which fails most often) even more difficult. When using a humeral hemiarthroplasty the humeral articular surface can be sized with respect to thickness and radius of curvature and positioned at the height, version, medial/lateral and anteroposterior configuration that best suits the kinematics of the shoulder after the arthritic glenoid has been managed by either a ream and run or a total shoulder arthroplasty.

The hemiarthroplasty technique involved removing the humeral head which, in a real patient, would be important for accessing the glenoid so that the glenoid arthroplasty could be optimized.

With in vitro testing in 20 different positions, the glenohumeral contact area (Table I), the mean contact pressure (Table II), and the peak contact pressure (Table III) were not significantly different among the three preparations (intact, resurfacing and hemiarthroplasty). The peak pressure was significantly elevated, compared with that in the intact condition, in five of the twenty positions following resurfacing and in two of the twenty positions following hemiarthroplasty.

The authors of this paper placed the apex of the humeral head significantly more superiorly following resurfacing than in the intact condition in two of the twenty positions. Using their technique, the apex of the humeral head was located significantly more superiorly following hemiarthroplasty than in the intact condition in all twenty positions. However, these authors did not use the many methods available for optimizing the position of the humeral head with respect to the reconstructed glenoid in the surgical management of glenohumeral arthritis, including adjusting the height, curvature, thickness, version, and eccentricity of the humeral head.

The authors' conclusions: "Resurfacing more closely restored the geometric center of the humeral head than hemiarthroplasty did, with less eccentric loading of the glenoid. Compared with hemiarthroplasty, humeral resurfacing may limit eccentric glenoid wear and permit better function because the glenohumeral joint biomechanics and the moment arms of the rotator cuff and the deltoid muscle are restored more closely to those of the intact condition" seem valid in a cadaver model of a normal shoulder. However the realities of the clinical management of the arthritic shoulder do not suggest that a resurfacing provides the necessary access to the glenoid, where the real challenges lie, nor the flexibility in humeral head reconstruction that are offered by a stemmed humeral component. 

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