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).

Skydiving after shoulder arthroplasty - less is more.

An active skydiver had major issues with recurrent dislocations - some of which occurred mid-flight and were, therefore, life threatening. Over the years he had multiple procedures to control his dislocations, including Bankart repairs and an iliac crest bone graft to his anterior glenoid. While these controlled his dislocations, he developed progressive arthritis of his shoulder that prevented him from participating in his sport.

He wanted a surgical procedure that would enable him to return to skydiving. He elected a hemiarthroplasty. At surgery, his humeral head was essentially devoid of articular cartilage, however the glenoid was smooth, the iliac crest graft had healed, and there was no evidence of suture anchor prominence. The standard stemmed hemiarthroplasty was secured with impaction autographing. In spite of his numerous prior surgeries, a robust subscapularis repair was achieved.

By 11 months after surgery he was back at skydiving and sent video (he's the person in the white jump suit) - see this link.

Now four years after his hemiarthroplasty he sent an email letting us know that things are going well with his left shoulder. He reported that he is back to skydiving as much as he'd like, and even doing tandem jumps with students again. For the latter, he has been working out the gym pretty hard to increase strength so he can take larger students. 

He sent a few skydiving pictures from the last year, including a 3-way with friends,  jumping smoke in a local Memorial Day event.

Comment: This case demonstrates the importance of considering not only the shoulder problem, but the person with the shoulder problem. In this case, his desired level of function was achieved with a combination of a relatively straightforward procedure and a terrific rehabilitation effort on the part of the patient.

Follow on twitter: https://twitter.com/shoulderarth

Follow on facebook: https://www.facebook.com/frederick.matsen

Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

How you can support research in shoulder surgery Click on this link.

Here are some videos that are of shoulder interest

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

Shoulder arthritis - x-ray appearance (see this link)

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

The total shoulder arthroplasty (see this link).

The ream and run technique is shown in this link.

The cuff tear arthropathy arthroplasty (see this link).

The reverse total shoulder arthroplasty (see this link).

Shoulder rehabilitation exercises (see this link).

This is a non-commercial site, the purpose of which is education, consistent with "Fair Use" as defined in Title 17 of the U.S. Code.          

Note that author has no financial relationships with any orthopaedic companies.

Anatomic or reverse total shoulder for capsulorrhaphy arthropathy?

Capsulorrhaphy arthropathy is a condition in which arthritis follows a prior procedure for recurrent shoulder instability.

Some of these patients have arthritis related to prominent suture anchors (see this link and this link).

A recent article reported on the results of two approaches to the management of capsulorrhapy arthropathy.

Anatomic and Reverse Total Shoulder Arthroplasty for Dislocation Arthropathy Yield Comparable Functional Outcomes to Matched Cohort

These authors sought to compare outcomes of anatomic (aTSA) and reverse total shoulder arthroplasty (rTSA) for arthritis following prior shoulder stabilization (capsulorrhapy arthropathy) versus matched cohorts without previous stabilization surgery. 

They conducted a retrospective cohort study that compared 36 aTSA and 32 rTSA patients with prior shoulder stabilization with 3-to-1 matched cohorts with no prior shoulder instability or surgery. 

The functional outcomes were comparable for the two implant types.

The postoperative adverse events (AE) rate was 8.3% and 4.6% in the aTSA group and matched cohort, respectively.

The postoperative AE rate was 6.3% and 4.2% among the rTSA group and matched cohort, respectively.

The overall adverse event rate was not different between aTSA and rTSA.

 

Comment: This study does not demonstrate increased value to the patient from the use of the more expensive reverse total shoulder arthroplasty in the management of patients with capsulorrhaphy arthropathy.

For active individuals, we've found that the ream and run procedure (see this link) can be effective in the management of capsulorrhapy arthropathy while avoiding some of the types of adverse events seen in aTSA and rTSA (see this link and this link).

Follow on twitter: https://twitter.com/shoulderarth

Follow on facebook: https://www.facebook.com/frederick.matsen

Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

How you can support research in shoulder surgery Click on this link.

Here are some videos that are of shoulder interest

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

Shoulder arthritis - x-ray appearance (see this link)

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

The total shoulder arthroplasty (see this link).

The ream and run technique is shown in this link.

The cuff tear arthropathy arthroplasty (see this link).

The reverse total shoulder arthroplasty (see this link).

Shoulder rehabilitation exercises (see this link).

This is a non-commercial site, the purpose of which is education, consistent with "Fair Use" as defined in Title 17 of the U.S. Code.          

Note that author has no financial relationships with any orthopaedic companies.

Ream and run for capsulorrhaphy arthropathty and B2 glenoid

A 58 year old active man presented with pain and stiffness in his right shoulder after an open stabilization procedure performed years previously. His radiographs showed severe arthritis with posterior decentering of the humeral head on a posteriorly eroded glenoid.

Because he wished to avoid the risks and limitations of a plastic glenoid, he elected to have a ream and run procedure. This was performed without a preoperative CT scan, without a brachial plexus block, and without attempt to change glenoid version. His x-rays two years after surgery are shown below.

We recently received this note six years after his procedure. 

"I want to thank you for your dedication to the development of improved shoulder replacement procedures. I received a ‘ream and run’ replacement of my right shoulder back in March of 2015. Since then my shoulder’s range of motion has continued to increase and my upper body strength has improved significantly.

I have always lived a very active life that was increasingly hampered by the limits and pain in my old arthritic shoulder joint. Now -with my ‘robust shoulder’- I am back to full-on backcountry/Nordic skiing, hiking, biking, paddling, camping, scrambling, and so on."

The technique for the ream and run procedure is shown in this link.

How you can support research in shoulder surgery Click on this link.

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 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).

 

 

Ream and run for capsulorraphy arthropathy - great rehab effort

A man in his late 40's had pain and stiffness in his right shoulder. 28 years ago he had a labrum repair for chronic subluxation with a "fantastic result with 100% recovery." 13 years ago he re-tore his labrum throwing a baseball. At the time of his repair arthritis and severe cartilage damage was noted so the surgeon also did micro-fracture. After that he never recovered his range of motion or full pain relief, but was "functional". He could still play basketball until earlier this year and throw a baseball until about 2 years ago.  Less than a year ago he had a cortisone shot. It modestly improved range of motion, pain, and stiffness. However, he  immediately started getting more grinding and popping in my shoulder.

He presented to us 6 months later with the x-rays shown below.
Note the presence of suture anchors, the flattening of the humeral head, the large osteophytes and the medialization of the humeral head

On the axillary "truth" view, note the glenoid biconcavity and retroversion.

Because of his young age, his high desired activity level, and his risks to avoid the risks and limitations associated with a polyethylene glenoid, he desired a ream and run procedure.

His postoperative x-rays are shown below with an impaction grafted standard stem, low filling ratio, and a smooth glenoid concavity.

His axillary view shows the use of an anteriorly eccentric humeral head. The glenoid was reamed conservatively, without attempt to alter preoperative glenoid version.

 The centering of his humeral head is shown by first drawing a circle around the humeral articular surface.

 Finding the center of the circle.

 And drawing the perpendicular bisector of the line segment connecting the anterior and posterior edges of the reamed glenoid. Thee excellent centering is shon below.

One month after surgery, he sent this message and the photos below of his exercises. "It takes some loosening up each day before I get to this position. I get some 'snaps and pops' as I push it, but I haven't been concerned about them. I've been able to slowly but consistently improve each day.

I've also been rowing every other day, which is uncomfortable but not too too painful. I have not done any lat pull-downs yet because I don't have access to a machine, but I'm going to try to set up some bands to work with. I am able to use my arm for most basic daily things that don't require me to lift it.

I am now taking 3000 mg of acetaminophen and 7.5 mg meloxicam a day. I will run out of meloxicam tomorrow and was planning to switch to 440 mg of naproxen 2x a day, unless you suggest anything different. "

Here he's showing his exercises at 4 weeks post op. 

Abduction stretch

 Pulley

 Supine stretch

 Forward lean/table slide

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To see a YouTube video on how the ream and run is done, click on this link.

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How you can support research in shoulder surgery Click on this link.

We have a new set of shoulder youtubes about the shoulder, check them out at this link.

Be sure to visit "Ream and Run - the state of the art" regarding this radically conservative approach to shoulder arthritis at this link and this link

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages  arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Arthritis after shoulder dislocations = use of the reverse total shoulder

Reverse shoulder arthroplasty for instability arthropathy

These authors conducted a retrospective cohort of 25 patients having a reverse total shoulder for arthritis after multiple dislocations or after a procedure for glenohumeral instability with a mean follow-up of 6.6 years.  Eighty percent of the patients had a prior surgery for instability (36% of Latarjet or Bristow (7 patients) and capsular surgery for the others) and 20% had multiple closed reduction in their history. Mean delay between the initial procedure or first dislocation and the surgery was 50.3 years (SD 13.48 years). Thirteen percent of the 25 patients had a failed history of cuff repair (3 patients); an intact cuff was found for the others. Main risks factors for shoulder instability found were alcoholism in 15.4%, dementia in 7.7%, and Parkinson disease in 7.7% of the cases.

Active anterior elevation increased from 70° to 140° (p < 0.01) and external rotation from 9° to 21° (p = 0.02). The adjusted CS increased from 38 to 98 (p < 0.01). 

Two early post-operative complications were collected: one superficial infection and one spine fracture perhaps related to a long superior baseplate screw. 

At the latest follow-up,  38.10% had glenoid spurs, and 55% had scapular notching (see above x-ray).

These authors demonstrate that a reverse total shoulder can be an effective procedure for the management of post instability arthropathy. It is of interest that the average time from first dislocation to the shoulder arthroplasty was 50 years.

Here is a related article

Shoulder arthroplasty after prior anterior stabilization procedures: do reverses have better outcomes?

These authors compared the outcomes of 15 total shoulder arthroplasties (TSA) and 10 reverse total shoulder arthroplasties (RTSA)  after anterior stabilization surgical procedures. The TSA group’s mean age at surgery was 54.9 years, with an average follow-up period of 4.0 years. The RTSA group’s mean age was 65.4 years, with an average followup period of 3.3 years.

In the TSA group, 4 patients underwent prior bony procedures (27%), all of which were Bristow procedures. One underwent multiple other non-arthroplasty shoulder surgical procedures, and another underwent 4 previous arthroscopic surgical procedures. The remaining 11 patients underwent previous soft-tissue procedures that included the following: 7 with arthroscopic anterior labral repairs and 4 with open anterior capsular reconstructions.

In the RTSA group, 4 prior bony procedures (40%) were performed: 3 were Bristow procedures (1 patient also underwent a prior open rotator cuff repair) and 1 was a glenoid osteotomy. The remaining 6 patients underwent previous softtissue procedures that included the following: 3 with open anterior labral and capsular repairs (one of these with a total of 3 open reconstructive procedures), 2 with arthroscopic labral repairs, and 1 with a thermal capsulorrhaphy for instability with rotator cuff repair in the same setting. 

In the TSA group, all the subscapularis tendons were deemed of adequate quality in the operative reports.
In the RTSA group, 3 subscapularis tendons were intact, 3 were poor quality, 2 were scarred, and 1 was deficient; in 1 case, the tendon quality was not recorded in the operative report. The intact subscapularis tendons were repaired. One of the poor-quality tendons and one of the scarred tendons were repaired using suture. The remaining subscapularis tendons were left as tenotomies.

In the TSA group the rotator cuff tendons were documented as being of adequate quality in all patients.
In the RTSA group, the supraspinatus was intact in 2, partially torn or poor quality in 3, and absent (or with a full-thickness tear) in 4. The infraspinatus was intact in 5, poor quality in 1, and absent (or with a full-thickness tear) in 3. The teres minor was intact in 6, partially torn or poor quality in 2, and absent in 1. 

The Simple Shoulder Test scores improved from averages of 3.9 to 8.9 in the TSA group and from 3.4 to 11.2 in the RTSA group. 

There were no complications or re operations in the RTSA group. TSA patients had a 33% complication rate and a 20% reoperation rate. 2 TSA patients underwent revision to RTSA. One TSA was converted to RTSA after aseptic glenoid loosening, and one was converted to RTSA because of subsequent rotator cuff failure. One TSA patient had a dislocation, which was treated with closed reduction and did not require further surgery. 

Comment: Glenohumeral arthritis developing after prior surgery for anterior instability - "capsulorrhaphy arthropathy" - can be complicated by subscapularis, rotator cuff, glenoid bone deficiencies, and residual glenoid hardware. Each of these factors can complicate the surgeon's ability to achieve solid glenoid component fixation and a stable anatomic arthroplasty. It is of interest that the surgeons elected TSA in patients a decade younger than those having RTSA. The soft tissues were more compromised in the RTSA group.

Even though this is a small case series of patients that are dissimilar in some important ways, it does point out the challenges of attempting an anatomic TSA and the potential benefit of the RTSA in managing the complex pathology of arthritis after a prior instability repair.

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We have a new set of shoulder youtubes about the shoulder, check them out at this link.

Be sure to visit "Ream and Run - the state of the art" regarding this radically conservative approach to shoulder arthritis at this link and this link

Use the "Search" box to the right to find other topics of interest to you.

How you can support progress in shoulder surgery

You may be interested in some of our most visited web pages arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Shoulder arthroplasty after prior anterior stabilization procedures

Shoulder arthroplasty after prior anterior stabilization procedures: do reverses have better outcomes?

These authors compared the outcomes of 15 total shoulder arthroplasties (TSA) and 10 reverse total shoulder arthroplasties (RTSA)  after anterior stabilization surgical procedures. The TSA group’s mean age at surgery was 54.9 years, with an average follow-up period of 4.0 years. The RTSA group’s mean age was 65.4 years, with an average followup period of 3.3 years.

In the TSA group, 4 patients underwent prior bony procedures (27%), all of which were Bristow procedures. One underwent multiple other non-arthroplasty shoulder surgical procedures, and another underwent 4 previous arthroscopic surgical procedures. The remaining 11 patients underwent previous soft-tissue procedures that included the following: 7 with arthroscopic anterior labral repairs and 4 with open anterior capsular reconstructions.

In the RTSA group, 4 prior bony procedures (40%) were performed: 3 were Bristow procedures (1 patient also underwent a prior open rotator cuff repair) and 1 was a glenoid osteotomy. The remaining 6 patients underwent previous softtissue procedures that included the following: 3 with open anterior labral and capsular repairs (one of these with a total of 3 open reconstructive procedures), 2 with arthroscopic labral repairs, and 1 with a thermal capsulorrhaphy for instability with rotator cuff repair in the same setting. 

In the TSA group, all the subscapularis tendons were deemed of adequate quality in the operative reports.
In the RTSA group, 3 subscapularis tendons were intact, 3 were poor quality, 2 were scarred, and 1 was deficient; in 1 case, the tendon quality was not recorded in the operative report. The intact subscapularis tendons were repaired. One of the poor-quality tendons and one of the scarred tendons were repaired using suture. The remaining subscapularis tendons were left as tenotomies.

In the TSA group the rotator cuff tendons were documented as being of adequate quality in all patients.
In the RTSA group, the supraspinatus was intact in 2, partially torn or poor quality in 3, and absent (or with a full-thickness tear) in 4. The infraspinatus was intact in 5, poor quality in 1, and absent (or with a full-thickness tear) in 3. The teres minor was intact in 6, partially torn or poor quality in 2, and absent in 1. 

The Simple Shoulder Test scores improved from averages of 3.9 to 8.9 in the TSA group and from 3.4 to 11.2 in the RTSA group. 

There were no complications or re operations in the RTSA group. TSA patients had a 33% complication rate and a 20% reoperation rate. 2 TSA patients underwent revision to RTSA. One TSA was converted to RTSA after aseptic glenoid loosening, and one was converted to RTSA because of subsequent rotator cuff failure. One TSA patient had a dislocation, which was treated with closed reduction and did not require further surgery. 

Comment: Glenohumeral arthritis developing after prior surgery for anterior instability - "capsulorrhaphy arthropathy" - can be complicated by subscapularis, rotator cuff, glenoid bone deficiencies, and residual glenoid hardware. Each of these factors can complicate the surgeon's ability to achieve solid glenoid component fixation and a stable anatomic arthroplasty. It is of interest that the surgeons elected TSA in patients a decade younger than those having RTSA. The soft tissues were more compromised in the RTSA group.

Even though this is a small case series of patients that are dissimilar in some important ways, it does point out the challenges of attempting an anatomic TSA and the potential benefit of the RTSA in managing the complex pathology of arthritis after a prior instability repair.

=====

We have a new set of shoulder youtubes about the shoulder, check them out at this link.

Be sure to visit "Ream and Run - the state of the art" regarding this radically conservative approach to shoulder arthritis at this link and this link

Use the "Search" box to the right to find other topics of interest to you.

How you can support progress in shoulder surgery

You may be interested in some of our most visited web pages  arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Complex arthritis treated with a ream and run

A 50 year old active man from the East Coast developed pain and stiffness in his shoulder 34 years after a staple repair for anterior glenohumeral instability.  Four years ago a surgeon attempted staple removal, but was unsuccessful.

He presented to us with severely limited range of motion, an SST of 0 out of 12 and the x-rays shown below from his prior surgeon. These non-standard views made it difficult to assess what was going on with the shoulder, specifically the relationship of the staple to the humeral head and glenoid.

 We obtained a standard AP in the plane of the scapula.

and an axillary "truth" view.

These demonstrated contact between the staple and the humeral head and severe secondary degenerative joint disease with multiple loose bodies and a posterior glenoid cyst.

At surgery it was very difficult to remove this well-fixed barbed staple. It was necessary to cut the staple in two and to drill around each of the tines before extracting each of them with a needle-nosed vice grip.

With the staple removed, performance of a standard ream and run arthroplasty was straightforward.

On the evening of surgery he was able to achieve an easy 150 degrees of assisted elevation without the benefit of a brachial plexus block.

On the morning after surgery he was taking only Tylenol for pain and demonstrated his assisted motion before discharge:

=====

We have a new set of shoulder youtubes about the shoulder, check them out at this link.

Be sure to visit "Ream and Run - the state of the art" regarding this radically conservative approach to shoulder arthritis at this link and this link

Use the "Search" box to the right to find other topics of interest to you.

How you can support progress in shoulder surgery

You may be interested in some of our most visited web pages  arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'