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«This booklet provides important information for patients, families and referring physicians considering the ream and run procedure. Please read it ...»

-- [ Page 1 ] --

Shoulder & Elbow Service, University of Washington Department of Orthopaedics and Sports Medicine

Ream and Run for Shoulder Arthritis:

Conservative Reconstructive Surgery for

Selected Individuals Desiring Higher Levels of Activity

than Recommended for

Traditional Total Shoulder Joint Replacement

This booklet provides important information for patients, families and referring physicians considering the ream and

run procedure. Please read it carefully. If questions arise, please email Dr. Frederick Matsen at matsen@uw.edu.

The Ream and Run procedure is a type of surgical joint replacement for highly motivated active individuals with shoulder arthritis who wish to avoid the potential risks and activity limitations associated with the plastic socket used in traditional total shoulder replacement.

In the ream and run surgery, the arthritic humeral head (ball of the shoulder’s ball and socket joint) is replaced by a smooth chrome cobalt prosthesis fixed to the humerus (arm bone) by a titanium stem.

The bone of the arthritic socket is reamed to the desired shape and the raw bone surface is allowed to heal while the patient gently exercises the shoulder.

During the period of recovery a biological surface forms on this surface. Success requires technical excellence of the surgery and a steadfast commitment by the patient to a specific exercise and rehabilitation program.

Shoulder & Elbow Service, University of Washington Department of Orthopaedics and Sports Medicine What Are The Key Parts Of The Normal Shoulder Joint?

Normally the smooth round surface of the humeral head (ball of the shoulder joint) fits in the shallow, smooth, round glenoid socket and is held in position by the rotator cuff.

What Is Shoulder Arthritis?

Shoulder arthritis is a condition in which degeneration, injury, inflammation or previous surgery destroys the normally smooth cartilage on the humeral head and glenoid socket.

Shoulder & Elbow Service, University of Washington Department of Orthopaedics and Sports Medicine How Is Shoulder Arthritis Diagnosed?

Carefully standardized X-rays reveal the loss of space between the humeral head and glenoid that is normally occupied by cartilage, showing bone-on-bone contact.

What Is A Conventional Total Shoulder Replacement?

In a conventional total shoulder replacement, the arthritic surface of the ball is replaced with a metal ball that is attached to a stem, which fits in the humerus. The glenoid socket is resurfaced with a highdensity polyethylene (plastic)component that is fixed in position on the shoulder blade using cement.

Shoulder & Elbow Service, University of Washington Department of Orthopaedics and Sports Medicine What Are The Possible Risks and Limitations Associated With Total Shoulder?

While this is the most common procedure performed for shoulder arthritis, it does carry the possible risks that the plastic glenoid component will wear, loosen or even break over time, especially with heavy use. It is not possible to predict how long a plastic socket will last in each case because the use and geometry of each shoulder is different. For these reasons, most surgeons advise patients to avoid activities that involve impact, weights or heavy use.

What Is A “Ream And Run” Surgery For Shoulder Arthritis?

In a Ream and Run, the possible risks and limitations associated with the use of a plastic socket, as is used in a conventional total shoulder, are avoided. Instead of implanting a glenoid prosthesis, the arthritic glenoid socket is reshaped with a reamer so that a smooth concavity results.

Shoulder & Elbow Service, University of Washington Department of Orthopaedics and Sports Medicine The surface of the arthritic humeral head is replaced with a cobalt-chrome head with a titanium stem that is press fit down the inside of humerus so that only the smooth surface extends from the bone.

This procedure is performed through an incision between the deltoid and the pectoralis major muscles on the front of the shoulder. Before placement of the humeral head prosthesis, we additionally release adhesions and contractures and remove bone spurs and scar tissue that may limit range of motion. Our team of experienced surgeons, anesthesiologists, and surgical assistants usually perform this procedure in less than two hours.

Shoulder & Elbow Service, University of Washington Department of Orthopaedics and Sports Medicine How Is The Humeral Component Fixed In The Humerus?

While some surgeons cement the humeral component and others use implants that foster bone ingrowth, we find that these approaches (a) stiffen the bone making it more likely to fracture in a fall and (b) greatly complicate any revision surgery that may become necessary in the future. We prefer to fix the component by impaction grafting the inside of the humerus (using bone harvested from the humeral head that has been removed) until a tight press fit of the implant is achieved.

What Happens To The Raw Bone Surface Left After The Reaming Of The Glenoid?

Laboratory studies at the University of Washington have shown that the reamed socket (glenoid) can heal over with a smooth fibrocartilaginous surface. The illustration shows the socket surface just after reaming and six months later with the reddish fibrocartilage on the surface.





Shoulder & Elbow Service, University of Washington Department of Orthopaedics and Sports Medicine Similar regeneration often, but not always, occurs in patients having the ream and run procedure, as shown by the space between the metal ball and the bony socket on x-rays (demonstrated as (R)).

Here are the typical x-rays after a ream and run procedure.

Shoulder & Elbow Service, University of Washington Department of Orthopaedics and Sports Medicine Rehabilitation is started immediately after surgery using a continuous passive motion machine and stretching exercises under the supervision of an expert physical therapist.

Shoulder & Elbow Service, University of Washington Department of Orthopaedics and Sports Medicine In order for proper healing to occur, the patient must maintain the range of motion achieved at surgery with simple, frequent stretching exercises.

Attaining and maintaining, at least,150 degrees of forward elevation is critical to the success of this procedure.

Shoulder & Elbow Service, University of Washington Department of Orthopaedics and Sports Medicine Who Should Consider A Ream And Run?

Surgery for shoulder arthritis should only be considered when the arthritis is limiting the quality of the patient’s life and after a trial of physical therapy and mild analgesics to determine if non-operative management is sufficiently helpful. Severe arthritis is usually best managed by a joint replacement, either a total shoulder or a ream and run. The Ream and Run procedure is considered by those who are strongly motivated to put in substantial time and effort in the rehabilitation process to assure that proper healing occurs and who recognize that the pain relief and range of motion achieved with this procedure may not match that of a conventional total shoulder replacement. The ideal patient is healthy, active, and committed to work diligently to achieve a shoulder reconstruction that does not require plastic and bone cement.

A patient who has had a terrific recovery after this procedure states “R&R patients must be very motivated to endure the challenges of the rehab. I don’t think that this can be overstated. It is most certainly a tough, painful, and lengthy process, but most definitely worth it. As they say, ‘The juice is worth the squeeze,’ but patients must prepare themselves mentally for the journey and be willing to put in the work.” Studies have shown that for some patients the recovery time after a ream and run procedure can be substantially longer than that typically seen with a full total shoulder replacement.

Who Should Probably Not Consider A Ream and Run?

This procedure is unlikely to be successful in individuals with rheumatoid arthritis, depression, obesity, diabetes, Parkinson’s disease, multiple previous shoulder surgeries, prior shoulder joint infections, rotator cuff deficiency and severely altered shoulder anatomy. Patients who routinely use narcotic medication or who use tobacco are generally not candidates for this procedure.

What Are The Keys To Success Of A Ream and Run?

Success requires technical excellence of the surgery and a steadfast commitment by the patient to the exercise program until the desired range of motion can be achieved comfortably. Attaining and maintaining at least 150 degrees of forward elevation is critical to the success of this procedure. Patients point out that the recovery is progressive – often the shoulder continues to improve as long as two years after surgery.

How Does A Patient Prepare For The Ream and Run Procedure?

As for all elective surgical procedures, the patient should be in the best possible physical and mental health at the time of the procedure. Any heart, lung, kidney, bladder, tooth, or gum problems should be managed before surgery. Any infection may be a reason to delay the operation. Any skin problem (acne, scratches, rashes, blisters, burns, etc) on the shoulder, armpit, arm, forearm or hand should be resolved before surgery. The shoulder surgeon needs to be aware of all health issues, including allergies as well as the non-prescription and prescription medications being taken. For instance, aspirin and anti-inflammatory medication may affect the way the blood clots. Some medications, such as blood thinners, may need to be modified or stopped before the time of surgery.

Shoulder & Elbow Service, University of Washington Department of Orthopaedics and Sports Medicine What Happens After Surgery?

The Ream and Run is a major surgical procedure that involves cutting of skin, tendons and bone. The pain from this surgery is managed by the anesthetic and by pain medications. Immediately after surgery, strong medications (such as morphine or Demerol) may be administered, although we minimize the use of narcotics to speed the recovery of the bladder, bowel and balance. Patients are transitioned to oral medications the evening of surgery. We encourage the use of Tylenol and anti-inflammatory medications, such as Aleve, and continue these at least for the first 6 weeks after surgery. An intravenous infusion is used to replace fluids and to give antibiotics. This is usually removed on the second day after surgery. Antibiotics are given just before surgery and stopped on the first day after surgery.

While a blood transfusion is rarely necessary, we do send a blood sample to the lab for a type and screen. A urinary catheter is usually placed for male patients while they are under anesthesia before the surgery begins.

The shoulder rehabilitation program is started on the day of surgery. The patient is encouraged to be up and out of bed soon after surgery and to progressively reduce their use of pain medications. Hospital discharge usually takes place on the second day after surgery. Patients are to avoid lifting, pushing, or pulling more than one pound for the first six weeks after surgery.

What Is The Rehabilitation Program After Ream and Run?

Arthritic shoulders are stiff. Although a major goal of the surgery is to relieve this stiffness by release of scar tissue, it may tend to recur after surgery. To prevent the recurrence of stiffness, rehabilitative exercises are started by our experienced shoulder therapists immediately after surgery using continuous passive motion and stretching by the patient. In order for proper healing to occur, the patient must attain and maintain at least 150 degrees range of forward elevation. Achieving this range of motion within the first few days of the procedure is critical to the success of this procedure. For the first 6 weeks of the recovery phase, the focus of rehabilitation is on maintaining this range of flexion.

Shoulder & Elbow Service, University of Washington Department of Orthopaedics and Sports Medicine We avoid stretching in external (outward) rotation of the shoulder, so as to avoid failure of the tendon repair that takes place during the surgery. External (outward) rotation of the shoulder is limited to the “handshake position” with the hand pointing forward.

In addition to the stretching exercises, we recommend thirty to sixty minutes of aerobic exercise a day (stair climber, treadmill, brisk walking, stationary bike, etc.), as this has proven to be a very helpful part of the recovery process.

Shoulder & Elbow Service, University of Washington Department of Orthopaedics and Sports Medicine Pictured below are three of the exercises that will help the shoulder achieve the goal of over 150 degrees of forward elevation: the supine stretch (with assistance from other arm), the forward lean and the pulley.

Shoulder & Elbow Service, University of Washington Department of Orthopaedics and Sports Medicine Strengthening exercises are avoided during the first 6 weeks so as not to stress the tendon repair or the healing bone surface. At six weeks, gentle progressive strengthening exercises are started as described below. Internal rotation strengthening s avoided for three months and until it is completely comfortable.

It is critical that the patient be evaluated by our team at the six week post-operative mark. If motion full range of motion has not been achieved by this point, a manipulation of the joint under anesthesia might be considered.

What Is Involved With A Manipulation Under Anesthesia?

If the shoulder has not attained 150 degrees of comfortable forward flexion by the 6th post-operative week, a manipulation under anesthesia should be considered. This involves returning to the operating room for a secondary procedure (not an open surgery), which involves receiving general anesthesia and performing a gentle closed manipulation of the shoulder to re-obtain the 150 degrees of forward flexion. This manipulation is performed without making any further incisions. After the manipulation, the stretching rehabilitation program will be restarted.

What If My Arm Or Hand Swells After Surgery?

Swelling is not uncommon after the Ream and Run. This occurs mainly from removing bone spurs and reaming the socket, which causes a small amount of unavoidable bleeding. Swelling is best managed by squeezing a ball and elevating your arm on a pillow whenever possible. If the swelling gets to the point where the arm feels tight, be sure to let your surgeon know.



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