Friday, December 8, 2017

Ream and run, results at five to sixteen years after surgery

Functional Outcomes of the Ream-and-Run Shoulder Arthroplasty A Concise Follow-up of a Previous Report

These authors previously reported the results at an average of 4.5 years after treatment of 176 patients with the ream-and-run arthroplasty. In the present study, they present the patient self-reported functional outcomes and clinical implant survival of the original cohort at a mean of 10 years (range, 5 to 16 years). Eleven patients (6%) died, and 30 (17%) had <5 years of follow-up. The Simple Shoulder Test (SST) score at the time of the latest follow-up was a median of 11 points (interquartile range, 9 to 12 points) and a mean (and standard deviation) of 10 ± 2.6 points, out of a possible 12 points. The average 10 year (minimum 2 year)  results were comparable to the average 4.5 year (minimum 5 year0 results

In the initial report, 22 patients had subsequent procedures; these included 2 manipulations under anesthesia, 5 subscapularis repairs, 4 open soft-tissue releases, 1 arthroscopic release, 5 revision ream-and-run procedures, 6 revisions to a total shoulder arthroplasty, and 1 revision to a reverse total shoulder arthroplasty. Since the original report, 6 additional patients had a subsequent procedure: a revision ream-and-run procedure was done in 4 and conversion to a total shoulder arthroplasty in 2. None had revision to a reverse total shoulder arthroplasty. In total, 28 patients had subsequent procedures. This represents 19% of the 146 who had a definitive minimum 5-year follow-up, including the 11 who died without known revision, the 1 who had a stroke, the 28 with subsequent procedures, and the remaining 106 with an unrevised shoulder. Nine had conversion to a total shoulder arthroplasty. Approximately half of the subsequent procedures (n = 15, 54%) were performed in the first 2 years following the ream-and-run procedure, after which the rate of subsequent procedures decreased substantially.

The overall rate of subsequent procedures was 19%, and the rate of prosthetic revision was 12% at a mean of 10 years. These findings are similar to the results of a recent national registry study (see this link) showing a 15% rate of prosthetic revision after total shoulder arthroplasties performed during a comparable time frame (2000 to 2005). In contrast to total shoulder arthroplasties, which have been widely reported to be associated with increasing rates of subsequent procedures and implant revision at 5 to 10 years after surgery, the rate of subsequent procedures declined in this study after the first 2 years. This phenomenon is likely attributable to the lack of mid-term and long-term glenoid component failure.

The authors provide this example case of a patient with a preoperative SST of 3 out of 12 and these films

Seven years after surgery he reported the ability to perform all 12 of the 12 functions of the SST. His seven year x-rays showed remodeling of his glenoid with firm subchondral bone and a regenerated layer of soft tissue between the metal ball and the reamed bone.

Comment: It is of note that a large percentage of the repeat procedures were directed at the management of stiffness (manipulations and soft tissue releases) and subscapularis failure. The risk of these problems may be reduced by (1) avoiding overstuffing the joint, (2) reinforcing the importance of vigorous range of motion exercises in the early rehabilitation period (see this link), and (3) protecting the subscapularis repair (see this link). It is of note that only 9 of the 22 repeat procedures involved conversion to a total shoulder or a reverse total shoulder. 

The details of the ream and run continue to be refined. The current trend is to assure this procedure is performed on carefully selected, highly motivated individuals whose activity levels may put a plastic glenoid component at risk for failure and to use relatively thinner humeral head components to allow for greater joint laxity. 

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