Which patients are at risk for stiffness after a ream and run glenohumeral arthroplasty?

Patients with glenohumeral arthritis considering shoulder arthroplasty may wish to avoid the activity limitations and the risk of complications associated with the polyethylene glenoid component used in traditional total shoulder arthroplasty. Avoiding the prosthetic glenoid component eliminates the risk of revision related to glenoid wear, glenoid loosening, and humeral component loosening associated with polyethylene wear. These patients may elect the ream and run glenohumeral arthroplasty (RnR) (see this link).

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.

Comment: While the overall outcome for these 340 patients were good - the SST improved from 5 out of 12 preopeartively to 10.2 out of 12 at two years after surgery - there are lessons to be learned from this study.

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. 

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).

Reverse total shoulder - why take x-rays in the recovery room?

 Clinical Utility of Immediate Postoperative Radiographs following Uncomplicated Primary Reverse Shoulder Arthroplasty

These authors reviewed the the recovery room (PACU) x-rays and other 90 postoperative films of 157 patients having uncomplicated primary reverse total shoulders. 

Immediate postoperative radiographs were read by the radiologist as normal/unremarkable for 100% of patients.  

13 patients had abnormal findings determined by the surgeon during the initial 3 month postoperative period.  

Ten out of 13 patients had radiographic findings at the first postoperative clinic visit that differed from the initial radiologist interpretation documented on the PACU radiograph.

The most common complication was instability and dislocation, which occurred in 9 patients. Additional complications included baseplate failure,  glenosphere dissociation, and humeral stem subsidence. Twelve of the 13 patients underwent revision surgery.

The authors concluded, "Based on our findings we see utility for an intra-operative or immediate postoperative radiograph following uncomplicated, primary reverse shoulder arthroplasty, especially when done as a salvage procedure for indications such as proximal humerus non-union. However, there is low utility for obtaining an immediate postoperative radiograph in the PACU when indications include osteoarthritis or rotator cuff tear arthropathy."

Comment: In contrast to these authors, we believe that it is important to obtain good quality postoperative x-rays in each case of reverse total shoulder arthroplasty, regardless of indication. The first reason is that these films provide the surgical team with immediate feedback on whether or not they realized their preoperative plan with respect to component positioning, screw placement, baseplate seating, humeral component positioning and humeral component fixation. 

Second, a "normal/unremarkable" reading by a radiologist may overlook abnormal findings of importance to the shoulder surgeon, such as the incomplete glenosphere seating shown below. Such a finding, even in a routine case may prompt a return to the OR from the PACU.

A third reason for taking a PACU x-ray is shown by the table from the article:

Case 5 (RSA for cuff tear arthropathy) was found to have baseplate failure 2 weeks after the procedure

Case 8 (RSA for massive cuff tear) was found to have a glenosphere dissociation a 3 weeks after the procedure.

Case 12 (RSA for massive cuff tear) was found to have a dislocation at two weeks after surgery

Case 13 (RSA for avascular necrosis) was found to have a greater tuberosity at 6 weeks after surgery.

In each of these cases of early failure it seems likely that there was a technical problem at surgery and that a careful examination of good quality PACU films might have identified the issue in a more timely manner.

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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 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).

Postoperative x-rays - accuracy and reliability

Accuracy and reliability of postoperative radiographic measurements of glenoid anatomy and relationships in patients with total shoulder arthroplasty.

The authors examined thirty-two x-ray images and computed tomography scans were taken within 1 month of each other in patients who had undergone total shoulder arthroplasty with an all-polyethylene glenoid component.

They found fair-moderate agreement between x-ray images and CT scans for coronal superior-inferior plane and version measurements, but poor agreement for humeral scapular alignment in the axial plane. They noted an average difference of overestimating coronal superior-inferior plane by 0.06% ± 7.7% and overestimating version by -4.2° ± 5.1°.

It is important to recognize, however, that the position of the arm and scapula were quite different for axillary radiographs and the axial CT scans, so it not at all clear that the differences are indicative of a lack of accuracy of the axillary view.

The authors recommend the use of postoperative Grashey radiographs for measurement of coronal superior-inferior plane and axillary radiographs for measurement of glenoid retroversion.

We have not found that the increased cost and radiation exposure of a CT scan are merited to assess glenohumeral anatomy in the great majority of cases.

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


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Immediate postoperative x-rays - value?

Immediate Postoperative Radiographs After Shoulder Arthroplasty Are Often Poor Quality and Do Not Alter Care

It is always wonderful when folks question the value of a practice: does the benefit justify the cost?

The issue with this paper is whether the authors are answering the question for all of us, or just for themselves. 

What this paper really says is that the authors found it difficult to obtain high-quality, postoperative shoulder radiographs immediately after surgery. Furthermore their postoperative underpenetrated single-view radiographs taken in internal rotation did not change their postoperative management and were not considered adequate to serve as a baseline for followup studies. Appropriately, they questioned the value of their routine postoperative radiographs after shoulder arthroplasty.

Their retrospective study showed that when postoperative films were taken later on in their office, they were able to obtain multiview radiographs, and most were deemed adequate to serve as baseline radiographs. 

Our experience is a bit different. For example, here are the recovery room films on a man who came from another state for a total shoulder on his second side.

These films enabled us to reassure ourselves and him that his alignment and prosthetic fixation were as expected. They will serve as the baseline films for our prospective followup study of shoulder outcomes. He left the medical center with a printed copy of these films for his personal file for comparison should he need additional films near home before our routine followup.

To be fair, the radiology techs that work in our recovery room are well trained in taking shoulder radiographs and each of our post operative films is personally supervised by a member of the surgical team (resident, fellow or attending surgeon).

So the point is that postoperative films can be of good quality and and be helpful in clinical management, but one needs to exert quality control to make sure the value is there.

Epilogue:
No sooner do I get this post up, and one of my best friends (the kind who always shoots straight with me) fires back: "I continue to question whether taking good [recovery room films] adds value. I can't answer this for the shoulder. I'm pretty sure that my practice of taking PACU films does not add value.  I've never diagnosed a knee fracture on one of these films (knock wood), and as far as I can tell, have never changed management based on one of these films.

Of all the points made in your commentary, the value argument even for good-quality films is the least compelling for me, but, again, I'm not a shoulder guy. For example, the concept of using them for a prospective study is particularly iffy – I assume the cost is not covered by a research grant – and I think the value of using them as a take-home for patients probably needs to be substantiated.

My general sense is that it should be incumbent on those of us who order a test (such as me ordering PACU films on knees) to prove their value, otherwise we should desist."

In a country where health care costs are rising without bound, we need to ask these tough questions.

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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 including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery.


See from which cities our patients come.


See the countries from which our readers come on this post.

Shoulder arthritis: antibiotics after joint replacement

A common question after a shoulder joint replacement surgery regards taking antibiotics for future procedures. Obviously the goal is to minimize the risk of bacteria in the bloodstream that may result in an infection of the joint replacement.

Our usual recommendations are that (1) any elective dental (cleaning, root canals, gum surgery, etc) or other surgical procedure should be done at least six weeks before the joint replacement and the wounds should have healed completely, (2) no elective surgery be done within three months after the joint replacement and (3) prophylactic antibiotics be used for life after a shoulder joint replacement for arthritis. Of course, individual treatment plans need to be developed for individuals - these are only general guidelines based on the 2009 recommendations of the American Academy of Orthopaedic Surgeons. I recommend that you take a moment to read their information statement on antibiotics.

Often our recommendations are:

Dental work: 2 grams of cephalexin 1 hour prior to the procedure for individuals without penicillin allergy, 600mg of clindamycin 1 hour prior to the dental procedure for individuals with penicillin allergy.

The AAOS recommendations for other procedures are shown below.

Again, these are only general guidelines. The specifics for an individual patient must be established by the treating physician/surgeon.

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

You may be interested in some of our most visited web pages including: shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery.

See the countries from which our readers come on this post.