In spite of what may be a more challenging rehabilitation and a greater risk of stiffness, these patients may consider the ream and run procedure (RnR), a glenohumeral arthroplasty that does not employ a prosthetic glenoid component (see this link).
Thus, one can see from the outset that patients electing the RnR are different that those electing aTSA, even though their history, physical examination and x-ray findings may be similar. Important differences may lie in domains that are challenging to quantify: resilience, optimism, goals, motivation, pain tolerance, and type of desired occupational and recreational activity.
The 39 patients having aTSA improved from an average preoperative SST of 4.1 to 10.9 at followup and from an average preoperative ASES score of 33.3 to 89.9 at followup.
Three patients underwent revision arthroplasty after RnR because of pain without obvious signs of infection at a mean of 1.9 years. One of the 3 patients had repeat RnR, with an excellent final outcome. Cultures were positive for Cutibacterium, and the humerus was loose at revision. A second patient was revised to aTSA and had positive Cutibacterium cultures at revision. The third was revised to RSA; culture data were unavailable. No manipulations or capsular releases were performed after RnR.
Two patients underwent revision arthroplasty after aTSA for glenoid loosening, at 9.2 and 14 years after aTSA, and both were treated by conversion to a hemiarthroplasty. At revision, all cultures were positive for Cutibacterium for 1 patient, and negative for the other.
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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).
The characteristics and outcomes for patients having RnR are compared to those of a concurrent series of patients having aTSA by the same surgeon in Ream and run and total shoulder: patient and shoulder characteristics in five hundred forty-four concurrent cases. In that report, the outcomes of the RnR and aTSA were similar: the average two year SST score for the RnRs was 10.0 vs. 9.5 for the aTSAs. The percent of maximum possible improvement (%MPI) for the RnRs averaged 72% vs. 73% for the aTSAs. While the outcomes were similar, the patients electing the RnR were different than those electing aTSA: patients selecting the RnR were more likely to be male (92.0% vs. 47.0%), younger (58 vs. 67 years), married (83.2% vs. 66.8%), from outside of the state (51.7% vs. 21.7%), commercially insured (59.1% vs. 25.2%), and to have type B2 glenoids (46.0% vs. 27.8%) as well as greater glenoid retroversion (19 vs. 15 degrees). Female patients having RnRs did less well than those having TSAs. However, this study did not attempt to capture other psychosocial characteristics that may be essential determinants of the arthroplasty choice and outcome mentioned above (resilience, optimism, goals, motivation, pain tolerance, and type of desired occupational and recreational activity). Furthermore the choice and outcome of aTSA and RnR depend heavily on the experience and enthusiasm that the surgeon has for the two procedures as described in The ream and run: not for every patient, every surgeon or every problem.
Based on the practice of an individual surgeon with extensive experience and expertise in both aTSA and RnR, the authors of Comparison of Humeral-Head Replacement with Glenoid-Reaming Arthroplasty (Ream and Run) Versus Anatomic Total Shoulder Arthroplasty A Matched-Cohort Study sought to compare the outcomes of RnR versus aTSA in younger patients with advanced glenohumeral osteoarthritis in a retrospective study of 110 patients who underwent aTSA and 57 patients who underwent RnR. Patients were <66 years of age and had a minimum of 2 years of follow-up.
Propensity matching was performed using 21 preoperative variables, eliminating from analysis those patients that could not be matched. 39 patient pairs representing 35% (39/110) of the aTSAs and 68% (39/57) of the RnRs were matched. All patients were male, with a mean age of 58.6 years and a mean follow-up 4.4 years.
The 39 patients having aTSA improved from an average preoperative SST of 4.1 to 10.9 at followup and from an average preoperative ASES score of 33.3 to 89.9 at followup.
The 39 patients having RnR improved from an average preoperative SST of 4.7 to 10.3 at followup and from an average preoperative ASES score of 34.8 to 85.0 at followup.
At the time of final follow-up, using inverse probability-weighted data from all 167 patients, 22.9% were dissatisfied after aTSA, while 9.4% were dissatisfied after RnR.
At the time of final follow-up, using inverse probability-weighted data from all 167 patients, 22.9% were dissatisfied after aTSA, while 9.4% were dissatisfied after RnR.
Three patients underwent revision arthroplasty after RnR because of pain without obvious signs of infection at a mean of 1.9 years. One of the 3 patients had repeat RnR, with an excellent final outcome. Cultures were positive for Cutibacterium, and the humerus was loose at revision. A second patient was revised to aTSA and had positive Cutibacterium cultures at revision. The third was revised to RSA; culture data were unavailable. No manipulations or capsular releases were performed after RnR.
Two patients underwent revision arthroplasty after aTSA for glenoid loosening, at 9.2 and 14 years after aTSA, and both were treated by conversion to a hemiarthroplasty. At revision, all cultures were positive for Cutibacterium for 1 patient, and negative for the other.
Comment: The authors of Comparison of Humeral-Head Replacement with Glenoid-Reaming Arthroplasty (Ream and Run) Versus Anatomic Total Shoulder Arthroplasty A Matched-Cohort Study are to be congratulated on their analysis of patients having aTSA and RnR leading to a better understanding of the management of the younger patient with glenohumeral arthritis. This paper is discussed in Can We Reliably Compare Outcomes of Ream-and-Run and Anatomic Total Shoulder Arthroplasty?
Taken together, this paper and the others identified above help illustrate the complexity of characterizing patients prior to these two types of anatomic shoulder arthroplasty (aTSA and RnR) as well as characterizing the outcomes of surgery.
It seems clear that
(1) carefully selected patients with glenohumeral arthritis can do well after either ream and run or anatomic total shoulder arthroplasty when the procedures are performed by experienced surgeons
(2) the patients selecting these two procedures differ in many important ways (e.g. age, sex, psychosocial factors, glenoid morphology, resilience, motivation, pain tolerance, and activity expectations) some of which are difficult to quantify in a meaningful way; this creates substantial difficulties in comparing outcomes.
(3) while propensity matching is a useful method for analysis, it results in the exclusion of a substantial number of patients from analysis and, by intent, obscures the differences in the characteristics of patients having each of the two procedures.
(4) the practices of surgeons experienced in these two methods is biased by their analysis of past cases; their selections, techniques and outcomes may not be generalizable to surgeons with less experience in patient selection and the techniques of the two procedures
(5) shoulder arthroplasty failure is commonly associated with positive Cutibacterium cultures at the time of revision surgery
(6) followup of 10 years or longer is required to capture the rates of glenoid component failure in total shoulder arthroplasty whereas the failures of RnR appear to become evident substantially earlier.
(7) Usually, when a RnR is revised, the surgeon has substantial glenoid bone stock for revision to another RnR, an aTSA or a reverse shoulder arthroplasty (RSA). By contrast, the management of a failed glenoid component after aTSA can be challenging: revision to RSA for glenoid loosening after aTSA is associated with a high rate of baseplate failure
(8) Whether a patient is "satisfied" with the outcome of a shoulder arthroplasty depends on the patient's preoperative expectations and the degree to which these expectations are met after surgery.
(9) In answer to the question, "is RnR or aTSA better?", the best answer may be "it depends on the patient, the shoulder and the surgeon" (see The ream and run: not for every patient, every surgeon or every problem). The surgeon is the method.
(10) For each of these two types of anatomic shoulder arthroplasty, future clinical research should explore the relationship of postoperative patient comfort, function, satisfaction and activity levels to preoperative patient and shoulder characteristics, including such factors as resilience, optimism and expectations.
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).
