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

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

This article was invited by International Orthopaedics. The abstract is reproduced here.

The purpose of this paper is to provide some essential and basic information concerning the ream and run technique for shoulder arthroplasty.

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. This paper explains in detail the principal factors in patient selection and the key technical elements of the procedure. Clinical examples and outcomes are demonstrated.

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Consultation for those who live a distance away from Seattle.

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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'

Rotator cuff repair - what patient and surgical factors matter in the outcome?

Specific patient-related prognostic factors for rotator cuff repair: a systematic review.

These authors conducted a literature search up to July 2013 for prospective studies that describe prognostic factors affecting outcome in primary open or arthroscopic repair of a full-thickness supraspinatus or infraspinatus tear.

Included outcome measures were shoulder function and cuff integrity; 12 studies met the inclusion criteria..

They defined a 'moderate' effect as one supported by by statistically significant findings in outcome measures in at least 1 high-quality prognostic cohort study or supported by consistently statistically significant findings in outcome measures in at least 2 medium quality prognostic cohort studies.

We tabulated the results of this carefully done study below, showing the strength of the relationships between different variables and (1) shoulder function and (2) repair integrity

Comment: This study again shows the difference in the factors associated with poorer function and those associated with failure of the repair to achieve tendon integrity. It also reminds us that the characteristics of the tear and the patient's age are the dominant factors in determining the chances of achieving a durable repair integrity.

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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'

The role of the condition of the patient in the result of surgery

We have been impressed by the body of evidence indicating that among the 4Ps (problem, patient, physician, procedure), the patient is a very important determinant of the result of treatment. As William Osler observed, 'It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.". Over the last several years we have noted data supporting what "our friend Bill" said many years ago.

Here are some of our posts demonstrating the importance of the patient - some relate to shoulder surgery and others to other procedures.

General considerations
   Patient health and surgical risk
   Charlson Comorbidity Index
   Ten modifiable factors that can improve health and outcome

   Catastrophic thinking
   General health status
   Psychological distress
   Preoperative pain 1
   Preoperative pain 2
   Preoperative health
   Exercise
   Emotional health

Habits
   Alcohol Consumption and Complications
   Smoking - effect on healing
   Smoking - relation to pain 1
   Smoking - relation to pain 2
   Smoking - effect on cuff tear size

Demographic factors
  Age 1
  Age 2
  Effect of insurance and ethnicity
  Effect of income
  Medicaid
  Workers' compensation
  Compliance and worker's compensation

Bone quality
   Osteoporosis
   Osteoporosis #2

Medical conditions
   Diabetes 1
   Diabetes 2 - glycemic control
   Depression
   Mental health
   Atrial fibrillation

   Atrial fibrillation 2
   Hypertension
   Sleeplessness
   Sleep apnea
   Co morbidities, diabetes, smoking

Obesity
   Obesity 1
   Obesity 2
   Obesity 3
   Obesity 4
   Obesity 5

   Obesity 6

   Obesity 7

   Obesity 8

   Obesity 9

Mediations
   Asprin
   Opiod use 1
   Opiod use 2


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Ream and Run for Shoulder Arthritis - patients under 55 years - research foundation 7

It is well known that patients with shoulder arthritis who are 55 years of age or younger have special challenges related to their activity levels, their expected longevity, and their more complex forms of arthritis. Shoulder fellows Saltzman and Mercer investigated our results with the ream and run procedure in patients in this younger age group. Among 65 shoulders, nine required revision surgery. These had had an average of 3 surgeries on their shoulder prior to the ream and run, in contrast to the 56 unrevised shoulders which had had an average of 1 prior surgery. For the 56 unrevised surgery the Simple Shoulder Test functions that could be performed improved from a mean of 4 before surgery to a mean of 9.5 at an average of 43 months after surgery (p<.001). The results are shown in more detail below.

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Use the "Search the Blog" 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.

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

Ream and Run for Shoulder Arthritis - comparison to total shoulder - research foundation 6

We are often asked to compare the ream and run procedure to the total shoulder in the treatment of shoulder arthritis. Shoulder fellows Clinton, Franta and Lenters matched 35 consecutive patients for whom we had performed the ream and run to a similar group of patients for whom we had performed a total shoulder; they presented the results in an article comparing these two procedures. The characteristics of the two groups are shown in the table below.

The time course for recovery is shown in the table and figure below.

We concluded that in the hands of a surgeon experienced in the procedure, the ream and run procedure can offer similar functional recovery to that achieved in similar patients having total shoulder arthroplasty.

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Use the "Search the Blog" 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.

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

Ream and Run for Shoulder Arthritis - clinical series - research foundation 4

Our first major publication on the ream and run procedure was co authored by shoulder fellows Lynch, Franta, and Lenters along with resident Montgomery; a link to this article, "Self Assessed Outcome Two to Four Years after Shoulder Hemiarthroplasty with Concentric Glenoid Reaming" can be found here. Our patients assessed their own comfort and function before and sequentially after the ream and run using the Simple Shoulder Test. The patients ranged in age from 35 to 80 years of age.  Their scores improved from 4.7 to 9.4 out of a possible 12. These results were very similar to the results from our series of total shoulder joint replacements as shown in Table II of the article, shown below.

Using the ream and run, we were able to able treat shoulders with severe posterior erosion of the glenoid bone as shown below

and to center the prosthetic humeral head on a reconfigured and regenerated joint surface as shown below.

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Use the "Search the Blog" 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.

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

Total shoulder for arthritis: the results

In considering the value of a procedure, it is important to measure its effect on the overall health of the patient. Our shoulder fellow Boorman did such a study for total shoulder replacement and found that the effect of total shoulder arthroplasty on self-assessed health status is comparable to that of total hip arthroplasty and coronary artery bypass grafting.

As the reader will recall from previous posts regarding the Simple Shoulder Test (SST), we consider the patient's own assessment of shoulder comfort and function to be the 'gold standard' for evaluating the result of the treatment of a shoulder condition. Over fifteen years ago, we published a study on the Early Effectiveness of Shoulder Arthroplasty for Patients Who Have Primary Glenohumeral Degenerative Joint Disease, using the SST. Subsequently, our shoulder fellows Fehringer , Boorman, and Churchill used this tool in Characterizing the Functional Improvement After Total Shoulder Arthroplasty for Osteoarthritis. They found that total shoulder arthroplasty substantially improved the Simple Shoulder Test self-assessments of comfort and function in individuals with shoulder arthritis. On average, shoulders achieved approximately two-thirds of the maximum possible improvement, regardless of the preoperative level of function. A similar study, The magnitude and durability of functional improvement after total shoulder arthroplasty for degenerative joint disease, was published by our shoulder fellow Goldberg. The key data from this study are shown in the figure below.

Our fellows Antoniou and Rozencwaig studied the Correlates with comfort and function after total shoulder arthroplasty for degenerative joint disease. They found that male gender, preoperative physical function, social function, mental health and shoulder function before surgery were the strongest predictors of the quality of the result from total shoulder replacement. These same authors had previously investigated the correlation of comorbidity with function of the shoulder and health status of patients who have glenohumeral degenerative joint disease.

Our shoulder fellows Saltzman and Mercer published an important study entitled, Comparison of patients undergoing primary shoulder arthroplasty before and after the age of fifty. They found that younger patients having shoulder joint replacement were more likely to have complex forms of shoulder arthritis,  such as capsulorrhaphy arthropathy, rheumatoid arthritis, and posttraumatic athritis. Only 21% of the younger patients had primary degenerative joint disease, whereas 66% of the older patients had that diagnosis. These more complex forms of arthritis may complicate the surgery, the rehabilitation and the outcome of shoulder joint replacement.

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Use the "Search the Blog" 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.

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

The SST in tracking recovery of comfort and function after shoulder reconstruction, for example after a ream and run procedure.

One of the operations we offer to patients with shoulder arthritis is the ream and run procedure. We will discuss this operation more in subsequent posts, but in brief it is a method of shoulder joint replacement arthroplasty that avoids the potential risks associated with a plastic socket.

The chart above shows how the Simple Shoulder Test (SST) is used to document the recovery of patient self-assessed comfort and function after a ream and run procedure for shoulder arthritis. The data represent the average recovery from a consecutive series of over 100 patients with at least two years of post surgical follow-up. The vertical axis represents the total number of SST questions answered 'yes', while the horizontal axis represents the years after surgery. The dots show individual data points and the lines show the average (plus or minus one standard deviation) for all the patients.
Since, on average, patients having the ream and run live over 500 miles from our center, routine office visits are impractical for them.  Because patients mail or email their results to us, we have been able to keep close tabs on their recovery using the Simple Shoulder Test.

The full article was recently published in the JBJS and discussed in this post.
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We have a new set of shoulder youtubes about the shoulder, check them out at this link.

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

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

How you can support progress in shoulder surgery

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

An example, the SST in Degenerative Joint Disease of the Shoulder

To illustrate the way in which the  Simple Shoulder Test (SST) characterizes the status of the shoulder, here are the average SST results from over 2000 patients that came to us for total shoulder replacement for arthritis. Keep in mind that this represents the patients' assessment of their own shoulders. It serves as the starting point for treatment and for measuring the effectiveness of the treatment selected.

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We have a new set of shoulder youtubes about the shoulder, check them out at this link.

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

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

How you can support progress in shoulder surgery

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

The Simple Shoulder Test

The goal of treating a person with a shoulder problem is to improve his or her  comfort and function. With this purpose in mind, we developed the Simple Shoulder Test (SST) to enable each individual to evaluate each of their shoulders in their own terms before and sequentially after treatment. The SST, as it has come to be known, is convenient for both the patient and the doctor - it can be completed at home and emailed in to the doctor's office - so that the course of the shoulder can be followed for long periods of time. The SST is now used in many languages the word over as a 'universal currency' by which patients, shoulder conditions, and results of different treatments can be compared.  This simple tool enables orthopaedic surgeons to achieve long term follow-up on the course of recovery and the durability of different approaches to reconstruction of the arthritic shoulder. The abstract of one of our early publications using the SST is shown below.

The Simple Shoulder Test

Name _________________                       


Date this form is completed: ________

Please answer YES or NO for BOTH of your shoulders		RIGHT		LEFT
		YES	NO	YES	NO
1	Is your shoulder comfortable with your arm at rest by your side?	£	£	£	£
2	Does your shoulder allow you to sleep comfortably?	£	£	£	£
3	Can you reach the small of your back to tuck in your shirt with your hand?	£	£	£	£
4	Can you place your hand behind your head with the elbow straight out to the side?	£	£	£	£
5	Can you place a coin on a shelf at the level of your shoulder without bending your elbow?	£	£	£	£
6	Can you lift one pound (a full pint container) to the level of your shoulder without bending your elbow?	£	£	£	£
7	Can you lift eight pounds (a full gallon container) to the level of your shoulder without bending your elbow?	£	£	£	£
8	Can you carry twenty pounds at your side with this extremity?	£	£	£	£
9	Do you think you can toss a softball under-hand twenty yards with this extremity?	£	£	£	£
10	Do you think you can toss a softball over-hand twenty yards with this extremity?	£	£	£	£
11	Can you wash the back of your opposite shoulder with this extremity?	£	£	£	£
12	Would your shoulder allow you to work full-time at your regular job?	£	£	£	£

 F. A. Matsen

Matsen, F. A., 3rd, D. W. Ziegler, et al. (1995). "Patient self-assessment of health status and function in glenohumeral degenerative joint disease." J Shoulder Elbow Surg 4(5): 345-51.

One hundred three consecutive patients with primary glenohumeral degenerative joint disease completed standard questionnaires regarding their general health status (Short Form-36) and the function of their shoulder (Simple Shoulder Test). These patients' self-assessed health status indicated overall bodily pain, physical functioning, and physical role fulfillment scores that were significantly below those of population-based control groups. Self-assessed shoulder functions were likewise consistently below those of patients with normal shoulders. These deficits clearly indicated the problems that the patients desired to have resolved by treatment. The use of self-assessment questionnaires to routinely characterize patients with shoulder conditions is practical in the context of a busy practice. These data enable surgeons to understand the condition from the patient's perspective. This understanding should be central to the planning of treatment and to the evaluation of treatment effectiveness.




The simple shoulder test is responsive in assessing change following shoulder arthroplasty.


Responsiveness statistics are a useful means to compare different outcomes in terms of their ability to detect clinical change. While the responsiveness of the SST has been established for rotator cuff repair, it has not been determined for patients undergoing arthroplasty.


Patients undergoing shoulder arthroplasty (n=120) were evaluated prior to surgery and 6 months after. The evaluation included the SST, Disabilities of the Arm, Shoulder and Hand questionnaire, range of motion, and isometric strength. Responsiveness to change was assessed using standardized response mean (SRM), while longitudinal construct validity was evaluated using Pearson correlation. Receiver operating characteristics curves were plotted to determine clinically important difference of SST.

The SST and Disabilities of the Arm, Shoulder and Hand questionnaire were highly responsive (SRM, >1.70) for this population. For the assessment of impairment, range of motion (SRM, 0.64-1.03) was moderately to highly responsive, while isometric strength was minimally to moderately responsive (SRM, 0.32-0.69). The clinically important difference of the SST was established at 3.0 SST points. Pearson correlations indicated moderate associations between the change scores of the SST and the Disabilities of the Arm, Shoulder and Hand questionnaire (r=0.49).

The SST has been previously shown to be valid and highly reliable. The present results show that the SST is also responsive following shoulder arthroplasty and that it has a clinically important difference of 3.0 SST points. This should provide confidence to clinicians who wish to use a brief shoulder-specific measure in their practice.

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To see our new series of youtube videos on important shoulder surgeries and how they are done, click here.

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

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

How you can support progress in shoulder surgery

You may be interested in some of our most visited web pages   arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery