Ream and run - for the Young at Heart

We recently received this email from a man in Carloina:

"I'm looking on YouTube and emailing people. The only reason I'm doing this is cause this xxx of a Dr, Dr xxx of xxx was telling me not to waste my time with fairy tales. That the ream and run was not supported by science which had me total bummed had caused me to say a few things to him I probably shouldn't have. "

This of course brought to mind the song by old blue eyes

Fairy tales can come true, it can happen to you

If you're young at heart.

For it's hard, you will find, to be narrow of mind

If you're young at heart.

Of course, it's better to let Sinatra sing it (link)

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Rotator cuff tears in young patients are different from those in elderly patients.

Rotator cuff tears in young patients: a different disease than rotator cuff tears in elderly patients.

These authors conducted a systematic search for clinical studies evaluating rotator cuff tears in patients younger than 40 years. 12 Level IV studies (336 patients) were included. The mean age of the patients was 28 years (range, 16-40 years), with a mean follow-up of 39 months. There were 2 distinct subgroups. The majority of studies (7 of 10) showed that patients typically had a full-thickness tear with an acute traumatic etiology. However, within the subgroup of elite throwers, 5 of 6 studies demonstrated a majority of tears that were partial thickness stemming from chronic overuse. Rotator cuff repair improved pain and strength in almost all studies reporting on these parameters. Eighty-seven percent of patients reported they were satisfied. However, all studies examining elite throwers showed significant difficulty in returning to play (25%-97%).

Comment: The results of this study can be anticipated from a few basic observations. 

*The incidence of cuff tears increases with age. 

*Young shoulders are used more vigorously than older shoulders. 

*These two observations indicated that the rotator cuff tendon attachments to bone are stronger in younger individuals. 

*Stronger attachments require more force (trauma) or extraordinary repetitive use to disrupt them.

Rather than being a 'different disease', it is more likely that there is a continuum from acute traumatic tears in the healthy cuffs of young shoulders to chronic degenerative tears in the age-weakened cuffs older shoulders. 

What we would have liked to learn from this study is the healing rate of repairs of cuff tears in younger individuals, but this information is not included. Our current 'wisdom' is that acute traumatic tears in otherwise healthy shoulders respond well to acute repairs. Hopefully we can garner evidence to support this wisdom.

Of course all older rotator cuffs are not weak. See here.

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Biological interposition for shoulder arthritis in patients under 50

Clinical outcomes of hemiarthroplasty and biological resurfacing in patients aged younger than 50 years

Because of the risk of glenoid component failure in younger and more active individuals, there has been an interest in exploring alternatives to total shoulder arthroplasty. These authors report on 44 patients younger than 50 years of age, 23 having hemiarthroplasty alone (HA) and 21 having hemiarthroplasty with biological resurfacing (BR) of the glenoid using an interposed graft, such as a meniscus allograft (although it is not clear whether other types of graft, such as joint capsule, graft jacket, autogenous fascia lata, and Achilles allograft were used as well).

At a mean follow-up of 3.7 years, six of 23 patients in the hemiarthroplasty and 12 of 21 patients in the biological resurfacing group had either revision surgery or an American Shoulder and Elbow Surgeons score <50.

The young age of these patients is of great interest. The 20 shoulders available for follow-up in the HA group were a mean age of 33.9 ± 9.4 years (range, 16.8-49.6 years). The 20 shoulders available for follow-up in the BR group were a mean age of 37.7 ± 8.9 years (range, 19.0-53.7 years).

It is also of interest that many of these patients had prior surgery. Ten HA patients had no prior surgery, and 10 were noted to have had at least 1 prior surgery. These operations included arthroscopic debridement (n = 7), stabilization (n = 10), superior labrum anterior posterior repair (n = 2), resection for chondroblastoma (n = 1), and bony glenoid reconstruction (n = 1). Eight BR patients had undergone no prior surgery, with 12 patients noted to have had at least 1 prior surgery, which included stabilization for recurrent instability (n = 15), arthroscopic debridement (n = 5), loose body removal (n = 2) and thermal capsulorrhaphy (n = 1).

Many of these patients had diagnoses other than primary osteoarthritis. Primary indications for surgery in the HA group were avascular necrosis (AVN; n = 7), post-traumatic degenerative joint disease (DJD; n = 5), postsurgical DJD (n = 2), primary osteoarthritis (OA; n = 1), chondroblastoma (n = 1), glenoid dysplasia (n = 1), and rheumatoid arthritis (RA; n = 2).  Primary indications for surgery in the BR were postcapsulorrhaphy DJD (n = 10), OA (n = 6), and AVN (n = 1). 

These demographics drive home the point that young individuals with arthritis are quite different than the usual patients having shoulder arthroplasty. There is no 'ideal' treatment for these patients. While some may have avascular necrosis without glenoid pathology in which case hemiarthroplasty alone may be selected, this is unusual. When the glenoid is altered, especially if there is posterior glenoid erosion, some type of glenoid arthroplasty - either a ream and run or a total shoulder - may need to be considered. This report and others point out that 'biological resurfacing' may not be the procedure of choice.

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Keeled glenoid survivorship in young patients

Mid- to long-term follow-up of total shoulder arthroplasty using a keeled glenoid in young adults with primary glenohumeral arthritis.

The purpose of this study was to examine the mid- to long-term functional outcome and implant survival of total shoulder arthroplasty in patients under the age of 56 years with primary glenohumeral arthritis. Between 1992 and 2004, surgeons in 8 centers performed 52 such arthroplasties. Minimum follow-up of 5 years was available in 50 patients at a mean of 115.5 months postoperatively.

At a mean of 115.5 months, 37.5% of glenoids showed no loosening, 18.8% showed possible loosening, and 43.8% had definite radiologic loosening. Survivorship of the glenoid component with the endpoint being revision surgery for glenoid loosening was 98% at 5 years but declined to 62.5% at 10 years. When the humeral head was not positioned anatomically, the glenoid was 6.6 times more likely to require removal. The 10-year survival rate was 87.5% for glenoids that were concentric before surgery (A1 and A2) and only 50% for non-concentric glenoids (B1 and B2). All of the revisions were in the dominant arm.

Comment: The management of the arthritic shoulder, especially those with type B glenoids in individuals under the age of 56 years remains a challenge. While total shoulder is one option, the ream and run has also been used in this age group with encouraging results, especially in patients without prior surgical procedures on that shoulder.

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Shoulder arthroplasty in younger patients

Shoulder arthroplasty in patients 59 years of age and younger

This is a retrospective cohort study of shoulder arthroplasties performed within the Permanente integrated healthcare system between 2005 and 2010. There were 2981 primary arthroplasties followed for a median time of 2.2 years,  90 (3.0%) of which required revisions. This represents an annualized revision rate of 1.4% per year.

After adjusting for procedure type and diagnosis, patients of 59 years and younger had a two times higher risk of revision than older patients. The adjustment for diagnosis is important in that Salzman and Saltzman pointed out that younger patients with shoulder arthritis tend to have different types of shoulder arthritis than older patients.

The authors conclude that patients 59 years and younger have an increased risk of revision at early follow-up.

It is of interest that the younger group had (a) a significantly higher percent of males (65%) than the older group (47%), (b) significantly fewer white patients (77% vs 84%), (c) significantly more hemiarthroplasties (41% vs 25%) and (d) significantly different diagnoses than the older group.

The most common reasons for revision were glenoid wear/arthritis (31%), infection (14%), instability (13%), cuff tear (10%), glenoid implant loosening (8%), cuff tear arthropathy (7%), and glenosphere failure (6%).

Univariate analysis revealed that age, hemiarthroplasty vs total shoulder, humeral head resurfacing vs total shoulder, reverse vs total shoulder, other diagnosis vs osteoarthritis increased the risk of revision. Multivariate analysis found that younger age, hemiarthroplasty, humeral head resurfacing, and reverse total shoulder were associated with increased risk of revision.

Comment: There are a lot of considerations in deciding the best treatment for an individual with shoulder arthritis and the outcomes of the procedures. These need to be considered in the application of the results of this study. While this study attempts to compare hemiarthroplasty, resurfacing, total and reverse shoulder arthroplasty, it seems likely that the surgeons considered many factors about the patient, the shoulder pathology, and their personal expertise in selecting among these options. Their observation that reverses had a higher revision rate than total shoulders, for example, cannot be taken to suggest that the operations were done on comparable patients.

The selection of treatment for a patient is based on the four "P"s: the shoulder Problem, the characteristics of the Patient with the problem, the Procedure to be performed and the Physician performing the procedure.

Finally, it is to be remembered that a ream and run is not a hemiarthroplasty. In the former the glenoid surface is managed by concentric reaming; in the latter it is not. In our experience, glenoid wear has not been an issue after the ream and run procedure.

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Keeled glenoid for total shoulder in young adults

Mid- to long-term follow-up of total shoulder arthroplasty using a keeled glenoid in young adults with primary glenohumeral arthritis

This is a multicenter Level IV report of  52 total shoulders using a keeled glenoid to treat primary glenohumeral arthritis in patients aged 55 years or younger. Minimum follow-up of 5 years was available in 50 patients at a mean of 115.5 months postoperatively.

Survivorship of the glenoid component with revision surgery for glenoid loosening as the endpoint was 98%  at 5 years and 62.5% at 10 years. This is very interesting in that it indicates the annualized revision rate was 0.4% per year at year five and 3.8% per year at 10 years. This accelerating annualized loosening rate is especially important considering the mean patient age of 50.5 at the time of surgery.

Complications requiring revision surgery were observed in 17 patients - over one third. Glenoid loosening was the most frequent complication that required revision and was observed in 12 cases. Other complications included 2 subscapularis ruptures, 1 case of humeral component loosening, 1 oversized humeral head component, and 1 case of postoperative stiffness. A total of 21 revision surgeries were performed in these 17 patients. 

For these reasons we continue to explore the role of the ream and run procedure in the management of glenohumeral arthritis in young / active patients.

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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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