The ream and run - a telling story of a very tough patient with a very tough problem

An active man, gym enthusiast, and off-road bike racer in his early thirties presented with a history of a multiple motorcycle crashes since the age of 18 resulting in posterior instability. His shoulder was treated with a series of cortisone injections and multiple attempts at posterior labral repairs.  Three years prior to presentation he had a glenohumeral debridement, revision posterior labral repair, along with an anterior and posterior capsular shift. One year prior to presentation he had a "bone spur" removal and biceps tenotomy. 

At the time of presentation, he had pain at rest and severe pain with movement of the shoulder which prevented him from his usual work as a contractor. 

On examination his shoulder was extremely stiff and painful on motion.

His radiographs showed severe glenohumeral arthritis with posterior decentering of the humeral head on a retroverted biconcave glenoid.

Wishing to avoid the limitations and risks associated with the polyethylene glenoid component used in a conventional total shoulder, he desired to proceed with a ream and run procedure (see this link). At this procedure there was no attempt to "correct" glenoid version.

His postoperative radiographs show an impaction autografted standard length, smooth stem with the humeral head centered on the reamed glenoid.

After surgery his shoulder was initially improved with respect to comfort and motion. However, he did not regain the desired motion and elected to proceed with a manipulation under anesthesia. The benefit from that procedure was only temporary. By eight months after his procedure his shoulder had become unbearably painful, hurting in most any position. The effort of using a keyboard or mouse, or rising from a seated position caused severe pain throughout his arm, initiating in the shoulder area but also radiating down past the elbow to the forearm.  Sleep was impossible because of this pain. 

His white blood cell count and sedimentation rate were normal. A fluid aspirate from his shoulder showed clear fluid with no growth on aerobic and anaerobic media at three weeks.

In spite of these normal results, it was elected to proceed with a revision procedure for suspected infection with single stage exchange of his implant.

At surgery, there was no evidence of synovitis. Synovial biopsy showed reactive hyperplasia, mononuclear inflammation and deposition of metallic particles, consistent with prosthetic joint wear debris, but no significant neutrophilic inflammation. 

Vigorous debridement and topical antibiotics were used. He was started on intravenous antibiotics immediately after surgery.

Eight deep tissue and explant cultures were obtained of which 6 grew Cutibacterium by 3 weeks after surgery.

After his course of IV antibiotics, he was placed on 6 months of oral Augmentin.

He has been diligently working on his range of motion and strength. He has had no postoperative episodes of instability.

His most recent x-rays (see below) show a secure humeral component without evidence of loosening or stress shielding, the humeral head centered on the retroverted glenoid, and a radiographic space between the head and the reamed glenoid.

Eighteen months after his revision he sent the following email:

"So, it has been a long time since I checked in, just want to let you know where I am at.  Shoulder is getting better as time goes by, still have some pain when it gets tired trying to lift it at times.  I believe this is all a result of weakness, when it is fresh and unused, I really have very little pain.  I have been back to work, pretty much full time. I am back to full time mountain biking and even have done a few local races, I have also tested it out by falling on it (fairly hard once).  I still have a long way to go strength wise to get it back but will continue to work on it. Here are couple pictures from racing this year. Yes, it went well at the races to 4^th and a 9^th in expert men’s, plan on doing more next year. " 

Comment: This case demonstrates 

1. the utility of the ream and run in a patient who loves to go fast with the risk of crashing

2. the ability of the ream and run to stabilize the humeral head on a retroverted glenoid without "correcting" glenoid version

3. the risk of periprosthetic infection after multiple prior surgeries in a young healthy man

4. the inability of standard blood, joint fluid and surgical histology to reveal a periprosthetic infection

5. the power of a patient's persistence and resolve

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Here are some videos that are of shoulder interest

Shoulder arthritis - what you need to know (see this link).

How to x-ray the shoulder (see this link).

The ream and run procedure (see this link).

The total shoulder arthroplasty (see this link).

The cuff tear arthropathy arthroplasty (see this link).

The reverse total shoulder arthroplasty (see this link).

The smooth and move procedure for irreparable rotator cuff tears (see this link).

Shoulder rehabilitation exercises (see this link).