Innovation gone bad. A sad beginning and happy ending: return to rock climbing after a ream and run plus an informative story of chondrolysis

In the early 2000s the innovation of using intra-articular pain pumps (devices for administering local anesthetics) were being marketed to manage post arthroscopic pain see The effectiveness of an anesthetic continuous-infusion device on postoperative pain control and The pain control infusion pump for postoperative pain control in shoulder surgery. It was not until a decade later that it was conclusively demonstrated that intra-articular pain pumps caused a devastating type of arthritis in young patients known as chondrolysis: Published evidence demonstrating the causation of glenohumeral chondrolysis by postoperative infusion of local anesthetic via a pain pump

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This is a poignant example of a technological innovation gone bad. We use the term "future shock" to refer to devastating complications from new technologies that are only discovered years after these devices are sold in the marketplace and used in patients. Chondrolysis remains one of the principal indications for shoulder arthroplasty in young individuals.

Consider a 21 year old active male who had a labral repair followed by the implantation of a pain pump. Ten years later he presented to us with progressive pain and stiffness of his shoulder; however he was still able to perform all 12 of the Simple Shoulder Test Functions. His x-rays at that time are shown below.

We advised him that he need not consider arthroplasty until his symptoms progressed.

Another decade later when he was in his early 40s, his symptoms had progressed as indicated by his Simple Shoulder Test

The radiographic appearance of his shoulder had substantially progressed as well.

To avoid the risks and limitations associated with a polyethylene glenoid component he elected to have a ream and run procedure. This was performed without preoperative CT scan, preoperative 3D planning, a nerve block, or an ingrowth humeral component. The long head tendon of the biceps was preserved, the glenoid was reamed conservatively to a single concavity, the thin humeral stem was fixed with impaction autografting.

Shown below are his follow-up x-rays.

 

As a part of his one year report he indicated, "I can do all my sports, and handle the kids with little and only temporary pain, and am even climbing at around the highest level I've ever climbed."  He kindly gave us permission to show some videos of his climbing.

You can support cutting edge shoulder research that is leading to better care for patients with shoulder problems, click on this link

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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). 

Rock climbing, swimming and the ream and run

Impact of 30 years’ high-level rock climbing on the shoulder: an magnetic resonance imaging study of 31 climbers

These authors sought to analyze the prevalence of pain and degenerative changes in the shoulder joints after highlevel rock climbing over at least 25 years in 31 adult male high-level rock climbers in comparison to controls.

On MRI examination, the rock climbers had significantly more abnormalities in the labrum (82% vs. 52%), long biceps tendon (53% vs. 23%), and cartilage (28% vs. 3%).  There were no significant differences between the 2 groups with respect to rotator cuff tendon pathology (68% vs. 58%) and acromioclavicular joint degeneration (88% vs. 90%). 

Despite the increased degenerative changes in the rock climbers, their Constant scores were still better than that of the nonclimbers.

The authors concluded that prolonged high-level rock climbing leads to a high prevalence of shoulder pain and increased degenerative changes to the labrum, long biceps tendon, and cartilage on shoulder imaging, but that these changes were not related to any restriction in shoulder function.

Comment: Serious rock climbers are very committed to their sport - a sport that requires both range of motion and strength. As a result, abnormalities on shoulder imaging may be less symptomatic in climbers than in a control group because the former continue to optimize their rehabilitation.

Serious climbers can develop advanced glenohumeral arthritis and are often concerned about the risks and limitations associated with the polyethylene glenoid component used in total shoulder arthroplasty. As a result, they may consider the ream and run arthroplasty which avoids a glenoid prosthesis.

Here is an example:

An active technical climber presented with a painful stiff left shoulder than was limiting his ability to pursue challenging international routes. Here is a photo of him climbing in Laos.

Below are his x-rays at presentation showing osteoarthritis and a biconcave glenoid with posterior decentering.

He had a left ream and run using an anteriorly eccentric humeral component. At one year after surgery is postoperative films show good alignment of his humeral head with his reamed glenoid in both views.

Note the anteriorly eccentric humeral head.

Here is a video of him climbing at 12 months after his left ream and run. Note the stretches!

He returned for a ream and run on the right shoulder.

His postoperative films are shown here.

Note the anteriorly eccentric humeral head.

Three months after his right shoulder arthroplasty, he sent this video of him "dry tooling" in his gym, stating that his shoulders are getting stronger everyday.

Here's a second example

A man in his late 50s from a couple of states South of here presented able to perform only half of the functions of the Simple Shoulder Test and with these radiographs of his arthritic left shoulder.

Here's his standardized axillary view. No CT scan or 3-D reconstruction was necessary.

His goal was to return to rock climbing after shoulder arthroplasty without having to worry about wearing out a plastic glenoid component. He elected to have a ream and run procedure. Here are his immediate postoperative x-rays showing prosthesis fixation with impaction grafting and the use of an anteriorly eccentric humeral head component that helped center his head on the glenoid. He also had a rotator interval plication.

At three months after surgery he had returned to sport climbing as shown here and on this youtube

https://www.youtube.com/watch?v=tnGZPwDbY34&t=9s

In our experience, rock climbers and swimmers tend to be excellent candidates for ream and run arthroplasty because of their commitment to flexibility.

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)

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).

Follow on twitter: Frederick Matsen (@shoulderarth)

Rock climbing after the ream and run

Case 1

An active technical climber presented with a painful stiff left shoulder than was limiting his ability to pursue challenging international routes. Here is a photo of him climbing in Laos.

Below are his x-rays at presentation showing osteoarthritis and a biconcave glenoid with posterior decentering.

One year ago he had a left ream and run using an anteriorly eccentric humeral component. His postoperative films show good alignment of his humeral head with his reamed glenoid in both views.

Four months ago he returned for a ream and run on the right shoulder.

His postoperative films are shown here.

This week he sent this video of him "dry tooling" in his gym, stating that his shoulders are getting stronger everyday.

This man has obviously put forth a terrific rehabilitation effort and it is paying off. 

Case 2

A man in his late 50ies from a couple of states South of here presented able to perform only half of the functions of the Simple Shoulder Test and with these radiographs of his arthritic left shoulder.

Here's his standardized axillary view. No CT scan or 3-D reconstruction was necessary.

His goal was to return to rock climbing after shoulder arthroplasty without having to worry about wearing out a plastic glenoid component. He elected to have a ream and run procedure. Here are his immediate postoperative x-rays showing prosthesis fixation with impaction grafting and the use of an anteriorly eccentric humeral head component that helped center his head on the glenoid. He also had a rotator interval plication.

At three months after surgery he had returned to sport climbing as shown here.

Here's a more recent video

Finally here's a bit of rope climbing after a left ream and run.

To see our technique for the ream and run click on this link. 

You can support cutting edge shoulder research and education that are leading to better care for patients with shoulder problems, click on this link.

Follow on twitter: https://twitter.com/RickMatsen or 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).