There is great current interest in the ream and run, the pyrocarbon humeral head and B type glenoids.

A recent publication, B2 and B3 glenoid osteoarthirtis: outcomes of corrective and concentric (C2) reaming of the glenoid combined with pyrocarbon hemiarthroplasty, reports a series of 41shoulders (in 35 patients, mean age of 57.9 years) that had a ream and run (glenoid reaming and humeral hemiarthroplasty without a prosthetic glenoid component) using a pyrocarbon humeral head. This procedure was offered to healthy young and/or active individuals (heavy workers or athletes) who had failed conservative management (cortisone injections, platelet-rich plasma, physical therapy) and who sought to avoid the activity restrictions and potential risks associated with anatomic or reverse total shoulder arthroplasty.

This study included patients with B2 (30 (73%)) or B3 (11 (27%)) glenoid pathoanatmy who had computed tomography (CT) performed with the arm at the side (1) before arthroplasty, (2) 6 months or less after surgery, and (3) at the last follow-up (>2 years).

The humeral stem was implanted in anatomic retroversion and inclination. Considering the additional thickness (+2 mm) of the metallic tray under the pyrocarbon head, the surgeon downsized the prosthetic head (one size lower than the trial head) to avoid overstuffing of the glenohumeral joint.

Glenoid reaming was performed to a "radius of curvature (ROC) close to that of the chosen prosthetic head (6-mm mismatch)" and "to correct 10 degrees of retroversion". This was carried out in two steps, first with a large radius of curvature to "partially (10 degrees) correct the excessive retroversion by reaming the high side (below top); a second reamer (with a small radius of curvature) was used to perform a concentric and congruent reaming" (below bottom).

This is in contrast to the standard ream and run technique in which the priority is preserving glenoid bone stock by minimizing the amount of bone removed and accepting the glenoid version (below).

The mean glenoid retroversion was changed by 9 degrees (from 17.1°preoperatively to 8.3°) at last follow-up.

Humeral centering on the glenoid was measured using Walch's mediatrice method where line "M" is the perpendicular bisector of the glenoid face and A divided by D is the percentage of the humeral head lying posterior to M.

The centering of the humeral head on the glenoid concavity was improved from 59.9% to 50.3% (50% being a completely centered humeral head).

The authors point out that that decentering of the humeral head on the glenoid was measured on CT with the arm at side and not with the arm elevated. Prior studies have shown that functional decentering of the humeral head on the glenoid occurs during arm elevation.

The medialization of the glenoid face relative to the body of the scapula was measured on CT scans after multiplane reconstruction: 2 planes, orthogonal to the scapular plane, were selected: (a) the plane tangent to the center of the glenoid surface (G) and (b) the plane tangent to the lateral cortex of the base of the coracoid (C). The distance between these 2 planes (C-G distance) was measured preoperatively and at each follow-up representing the amount of glenoid medialization. A positive value means that the glenoid surface is lateral to the base of the coracoid, whereas a negative value means that the glenoid surface is medial to the base of the coracoid .

The average total medialization was 3.7 ± 3.2 mm (2.0 ± 1.8 mm due to reaming and 1.7 ± 2.4 mm due to erosion occurring between 6 months or less after surgery and final followup.

The adjusted Constant Score increased from 43% to 97%; the Subjective Shoulder Value from 38% to 84%. 84% of active patients returned to work, and all patients returned to sports.

In comparison to images obtained 6 or fewer months after surgery, 11 (28%) shoulders showed progression of glenoid erosion by 1 grade, whereas 28 shoulders (72%) showed no increased glenoid erosion at the last follow-up. Shoulders with increased glenoid erosion of 1 grade had 9 points lower Constant scores and 9 percent lower subjective shoulder value scores than those with no increased erosion; no correlations were found between increased glenoid erosion and shoulder pain.

At a mean follow-up of 4.5 years, the prosthesis survival was 95% (39 of 41). No patient has been reoperated for painful glenoid erosion.

Comment: This is a very carefully done and clearly presented study. A major strength is that the authors used the same imaging method to assess the shoulder's geometry before and sequentially after surgery.

This paper confirms the utility of the ream and run procedure for young and active patients with B2 and B3 type glenoids who wish to avoid the limitations associated with anatomic and reverse total shoulder arthroplasty.

The authors point out that there is a risk of overstuffing the glenohumeral joint

with the pyrocarbon implant because of the presence of a metallic tray under the pyrocarbon head that increases the global thickness of the humeral head as shown in an annotated figure from their paper shown below.

Their study found that the amount of medialization for the ream and run with pyrocarbon was 1.7 mm between 6 months or less and 4.5 years after arthroplasty.

Here are two studies using metallic heads:

Shoulder hemiarthroplasty with concentric glenoid reaming in patients 55 years old or less (average medialization of 1.1 mm between immediate postoperative and a mean of 44 months after arthroplasty).

Clinical and Radiographic Outcomes of the Ream-and-Run Procedure for Primary Glenohumeral Arthritis (average medialization of 2.4 mm between immediate postoperative and a mean of 28 months after arthroplasty; glenoid type was not associated with the amount of medialization; the amount of medialization was not associated with the clinical outcome realized by the patient).

Conclusion:

The ream and run procedure is a reliable option for active patients who wish to avoid the risks and limitations of an anatomic or reverse total shoulder. Well controlled studies are needed to determine the importance of preoperative pathoanatomy, version modification, component position and humeral head material composition on the quality and durability of the clinical outcome realized by the patient following this 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).