Patient & Surgeon
The ream and run is a special procedure designed for special patients. To meet some of the patients who elected the ream and run, click on this link.
To emphasize that most patients have a choice between the ream and run and a total shoulder arthroplasty, we provide them with this handout The Total Shoulder Arthroplasty and the Ream and Run Procedure.
In our article, The ream and run: not for every patient, every surgeon or every problem, we emphasize that a successful ream and run procedure depends on selecting (1) the right shoulder problem, (2) the right patient and (3) the right surgeon.
The Shoulder
The ream and run is designed to treat disabling shoulder pain and stiffness from osteoarthritis in shoulders with a functioning rotator cuff and deltoid muscle.
The History
How did the shoulder problem start? How has the shoulder been managed (injections, therapy)?. What prior surgical procedures have been performed and how effective were they? Did the patient experience complications from anesthesia or surgery?
The anatomy of the shoulder
The bone of the humerus and glenoid needs to be of good quality without major deformity. Shoulders with osteoporosis, rotator cuff deficiency, instability, inflammatory arthritis (such as rheumatoid arthritis), infection, nerve injuries, and major deformities from past trauma, prior surgery, or birth defects are usually poorer candidates for the ream and run.
The pairs of figures below show three shoulders that are good candidates for the ream and run. On the left is severe arthritis with a massive osteophyte (bone spur) and no joint space between the ball and the socket. In the center is a shoulder in which the humeral head is posteriorly decentered on the glenoid. On the right is a shoulder with increased retroversion (posterior tilting) of the glenoid and posterior decentering of the humeral head on the glenoid.
Shoulders with preoperative posterior decentering may require special surgical techniques to balance the ball on the socket.
As can be seen from the examples above, the quality of the bone and the relationship between the humeral head and the glenoid can almost always be assessed on two standardized plain x-rays (rather than on CT scans). The first view is an anteroposterior view in the plane of the scapula. The second is an axillary "truth" view taken with the arm in a functional position of elevation. These are nicely shown on the diagrams below crafted by Steve Lippitt.
If there is concern about the integrity of the rotator cuff or subscapularis, an MRI may be indicated, although this is not usually necessary.
How flexible is the shoulder?
Shoulders with limited range of motion before surgery will require more vigorous surgical releases and more vigorous flexibility exercises after surgery.
How strong is the shoulder?
Shoulders that are weak prior to surgery may need evaluation of the rotator cuff and subscapularis using an MRI, especially if passive range of motion is substantially greater than active range of motion. Some commonly used strength tests are shown below.
How functional is the shoulder?
Shoulder function is most appropriately evaluated by the patient. Our patients use the extensively validated Simple Shoulder Test (SST) to document their self-assessed shoulder function before and sequentially after shoulder arthroplasty (Is the Simple Shoulder Test a valid outcome instrument for shoulder arthroplasty?). The SST consists of 12 "yes" or "no" questions regarding basic shoulder functions (see below).
Patients often ask, "how bad does my shoulder need to be before having a ream and run? We refer to this as the "tipping point". Two of our studies indicate that the typical tipping point for the SST is 5; in other words the typical patient can only perform 5 of the 12 SST functions before proceeding the the ream and run. However as can be seen, there is substantial variation among individuals.
The median preoperative value of the SST for patients having the ream and run procedure was 5 (interquartile range, 3-7) in The "tipping point" for 931 elective shoulder arthroplasties. The average preoperative value of the SST for patients having the ream and run procedure was 5.4±2.5) in Minimum 10-year follow-up of anatomic total shoulder arthroplasty and ream-and-run arthroplasty for primary glenohumeral osteoarthritis.
The Patient
Patients desiring the ream and run procedure are different than those having traditional total shoulder arthroplasty.
They wish to avoid the risks and activity limitations associated with the plastic socket (polyethylene glenoid component) used in traditional total shoulder joint replacement. In addition to wantiing to avoid these activity limitations, these patients differ in other fundamental ways from the typical patients having conventional total shoulder arthroplasty. As emphasized in Minimum 10-year follow-up of anatomic total shoulder arthroplasty and ream-and-run arthroplasty for primary glenohumeral osteoarthritis patients electing the ream and run procedure are significantly younger, healthier, more likely to be male, to have had prior surgery, to have involvement of the right shoulder, and to have type B glenoid pathoanatomy. An earlier paper, Comparison of patients undergoing primary shoulder arthroplasty before and after the age of fifty, pointed out that younger patients not only have greater longevity and higher activity expectations, but also have more complex shoulder pathological conditions, such as capsulorrhaphy arthropathy and posttraumatic arthritis. In fact only 21% of the younger patients had primary degenerative joint disease in comparison to 66% of the older patients.
To meet some of the patients who elected the ream and run procedure, click on this link.
In our practice, ream and run arthroplasty is reserved for patients who:
(1) have an understanding of the regenerative nature of the procedure and that it takes time for the reamed glenoid to heal to the desired smooth surface.
(2) are committed to following the rehabilitation program, recognizing that it make take longer than that for a conventional total shoulder arthroplasty; the focus is on gaining and maintaining the desired range of motion immediately after surgery through daily exercises and avoiding activities that risk the shoulder repair until it is well healed
(3) are in good mental, physical, and social health
(4) do not use narcotics, nicotine products, recreational drugs or more than modest alcoholic drinks
(5) have a good support system with family or friends who will assist in the recovery
(6) understand the specific risks of persistent pain, stiffness, glenoid erosion and the possible need for shoulder manipulation or revision surgery in addition to the general risks associated with any type of shoulder joint replacement (anesthetic complications, bleeding, infection, nerve injury, weakness, component loosening)
(7) understand that young male patients have an increased risk of infection after shoulder joint replacement related in part to their higher levels of testosterone (for this reason, supplemental testosterone is stopped two months prior to surgery) (Factors predictive of Cutibacterium periprosthetic shoulder infections: a retrospective study of 342 prosthetic revisions)(Association Between Serum Testosterone Levels and Cutibacterium Skin Load in Patients Undergoing Elective Shoulder Arthroplasty: A Cohort Study)
(8) consider participating in our ream and run followup program that provides invaluable information that we use in improving outcomes for our patients.
The Surgeon
The Surgeon is the Method
Since our first ream and run procedure 20 years ago, we are continuing to refine the procedure to address the specifics of each shoulder in each patient. Improvement comes not from technological innovations (such as 3D CT based planning and augmented reality), but from understanding of the factors that determine the shoulder's mobility and stability. This understanding comes from adhering to Codman's dictum; "follow each patient long enough to learn if the procedure was successful and if not to determine why not".
The Simple Shoulder Test has provided a cost effective way to follow our patients; much of what we now know has come from systematic patient followup over the last two decades using this patient reported metric.
Surgeons committed to developing proficiency with ream and run will not only learn from descriptions of the current technique (see the "Surgery" section), but will continually refine their method based on what does and does not work in their hands.