Some patients experience stiffness after the RnR which, if severe, can lead to repeat procedures such as a manipulation under anesthesia (MUA) or an open surgical revision. The authors of Risk Factors for Stiffness Requiring Intervention After Ream-and-Run Arthroplasty sought to determine risk factors associated with repeat procedures performed for postoperative stiffness after ream and run arthroplasty.
They identified 340 patients who underwent the ream and run arthroplasty in a longitudinally maintained database with a mean follow-up of 2.1 years. Patients who underwent a repeat procedure and the control group of patients who did not undergo a repeat procedure had similar preoperative mean SST scores (4.8 compared with 5.0) and SANE scores (38.8 compared with 41.0). The mean Simple Shoulder Test (SST) scores for all patients significantly improved from 5.0 preoperatively to 10.2 postoperatively. The mean SANE scores improved from 40.6 preoperatively to 80.3 postoperatively.
Thirty-five patients (10.3%) elected to undergo an MUA. These procedures were performed at a mean of 8.7 months after the index arthroplasty.
Twenty-six patients (7.6%) underwent subsequent open procedures to treat stiffness. Four patients underwent a conversion to an anatomic total shoulder arthroplasty; the remaining 22 patients had soft tissue releases and downsizing of the humeral head component thickness. These procedures were performed at a mean of 20.6 months (range, 0.9 to 71.7 months) after the index arthroplasty.
At the time of open revision, 69.2% (18 of 26) had ≥2 cultures positive for Cutibacterium.
Younger age, female sex, and lower American Society of Anesthesiologists (ASA) class were significant risk factors for repeat procedures. Patients who underwent a repeat procedure had greater preoperative posterior decentering (10.7% compared with 8.1%) but similar Walch classification and preoperative retroversion. Patients who required a repeat procedure had less forward elevation (125.7° compared with 143.3°) noted by an individual designated physical therapist at the time of hospital discharge after the index surgical procedure. Preoperative diagnosis, BMI, insurance type, employment, opioid use, smoking status, prior procedures on the same shoulder, head thickness, use of an eccentric head, and rotator interval plication were not significantly different between those who required repeat intervention and those who did not.
Patients who underwent a repeat procedure had lower mean scores at 2 years for the SST (8.2 compared with 10.6) and SANE (68.4 compared with 82.7). The mean SST scores of patients undergoing MUA (6.2) were significantly lower than those of patients undergoing open revision (9.7).
Multivariate analysis found younger age, ASA class 1 compared with class 3, and less passive forward elevation at discharge to be independent risk factors for repeat procedures.
Younger age, female sex, and lower American Society of Anesthesiologists (ASA) class were significant risk factors for repeat procedures. Patients who underwent a repeat procedure had greater preoperative posterior decentering (10.7% compared with 8.1%) but similar Walch classification and preoperative retroversion. Patients who required a repeat procedure had less forward elevation (125.7° compared with 143.3°) noted by an individual designated physical therapist at the time of hospital discharge after the index surgical procedure. Preoperative diagnosis, BMI, insurance type, employment, opioid use, smoking status, prior procedures on the same shoulder, head thickness, use of an eccentric head, and rotator interval plication were not significantly different between those who required repeat intervention and those who did not.
Patients who underwent a repeat procedure had lower mean scores at 2 years for the SST (8.2 compared with 10.6) and SANE (68.4 compared with 82.7). The mean SST scores of patients undergoing MUA (6.2) were significantly lower than those of patients undergoing open revision (9.7).
Multivariate analysis found younger age, ASA class 1 compared with class 3, and less passive forward elevation at discharge to be independent risk factors for repeat procedures.
Achieving immediate range of motion and maintaining it throughout the rehabilitation period is essential to the success of the ream and run procedure. Less forward elevation at the time of discharge from the hospital after a ream and run was an independent risk factor for a repeat procedure. This finding demonstrates that the finding of less than 130 degrees of flexion in the immediate postoperative period can identify patients who may benefit from a more aggressive early rehabilitation protocol.
Preoperative posterior decentering was significantly greater in the group that required repeat intervention. At surgery, posterior decentering may addressed by increasing the thickness or diameter of the prosthetic head, use of an anteriorly eccentric humeral head, and performance of rotator interval plication. These modifications that are carried out to help center the humeral head on the glenoid may contribute to postoperative stiffness,
Patients at risk for postoperartive stiffness may benefit from greater soft-tissue releases, smaller humeral head components, more aggressive rehabilitation, and close monitoring of their range of motion after the surgical procedure. Furthermore, surgeons should be alert to the possibility of Cutibacterium periprosthetic infection in shoulders developing stiffness after the ream and run procedure.
Younger age and better health were independent risk factors for repeat procedures to address stiffness. Younger patients may have higher expectations and, therefore, a lower threshold for a second procedure to address stiffness. It is also known that stiffness can be caused by a low grade periprosthetic infection from Cutibaterium. Young, healthy patients selecting the ream and run are at greater risk for these infections, which typically present as pain and stiffness in absence of the usual signs of periprosthetic joint infection from other bacteria (elevated serum markers, fever, chills, joint swelling, and a draining sinus). In Factors predictive of Cutibacterium periprosthetic shoulder infections: a retrospective study of 342 prosthetic revisions) the authors found that patients with definite Cutibacterium periprosthetic infections were younger (59 ± 10 vs. 64 ± 12, P < .001) and had lower American Society of Anesthesiologists scores (1.9 ± 0.7 vs. 2.3 ± 0.7, P < .001). In Risk Factors for Stiffness Requiring Intervention After Ream-and-Run Arthroplasty, over two-thirds (69.2%) of the open revisions for stiffness had multiple positive intraoperative cultures for Cutibacterium.
Preoperative posterior decentering was significantly greater in the group that required repeat intervention. At surgery, posterior decentering may addressed by increasing the thickness or diameter of the prosthetic head, use of an anteriorly eccentric humeral head, and performance of rotator interval plication. These modifications that are carried out to help center the humeral head on the glenoid may contribute to postoperative stiffness,
Patients at risk for postoperartive stiffness may benefit from greater soft-tissue releases, smaller humeral head components, more aggressive rehabilitation, and close monitoring of their range of motion after the surgical procedure. Furthermore, surgeons should be alert to the possibility of Cutibacterium periprosthetic infection in shoulders developing stiffness after the ream and run procedure.
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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).
Follow on twitter: https://twitter.com/shoulderarth
Follow on facebook: click on this link
Follow on facebook: https://www.facebook.com/frederick.matsen
Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/
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).
