Ream-Run

Summary

The ream and run procedure can restore comfort and function to the arthritic shoulder. In this procedure the arthritic ball is replaced by a smooth metal ball fixed to the arm bone (humerus) by a stem that fits within it. The bone of the arthritic socket is reamed to the desired shape and allowed to heal with a biological surface during the period of recovery after surgery. This proce- dure avoids the possible risks and limitations associated with a plastic socket replacement and with the cement used to fix it in position. Success requires technical excellence of the surgery and a steadfast commitment to the exercise program until the desired range of motion can be achieved comfortably.

If you have questions about this procedure please feel free to email Dr Matsen at matsen@uw.edu.

What Are The Key Parts Of The Normal Shoulder Joint?

The ball (humeral head) fits in the socket (glenoid) and is held there 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 ball (humeral head) and socket (glenoid).

How Is Shoulder Arthritis Diagnosed?

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

What Is A Total Shoulder?

In a total shoulder the arthritic surface of the ball is replaced with a metal ball with a stem that fits down the inside of the arm bone (humerus) and the socket is resurfaced with a high density polyethylene component. While this is a standard treatment for arthritis of the shoulder it does carry the possible risk that the plastic glenoid component will wear loosen or break over time especially with heavy use.

What Is A "Ream And Run" Surgery For Shoulder Arthritis?

The arthritic surface of the ball is replaced with a metal ball with a stem that is press fit down the inside of the arm bone (humerus) so that only the smooth surface extends from the bone.

After a general or regional anesthetic this procedure is performed through an incision between the deltoid and the pectoralis major muscles on the front of the shoulder. It includes release of adhesions and contractures and removal of bone spurs that may block range of motion. Our team of surgeons anesthesiologists and surgical assistants usually perform this procedure in less than two hours. Our shoulder therapists begin teaching the rehabilitation program the day of surgery.

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 stiffen the bone making it more likely to fracture in a fall on one hand and greatly complicating any revision surgery that may become necessary in the future on the other. 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?

Evidence that similar regeneration occurs in patients comes from the space shown on x-rays between the metal ball and the bony socket.

In order for proper healing to occur the patient must maintain the range of motion achieved at surgery with simple frequent stretching exercises. Rehabilitative exercises are started immediately after surgery using continuous passive motion and stretching by the patient.

Attaining and maintaining at least 150 degrees of forward elevation is critical to the success of this procedure. The forward lean and the supine stretch can be helpful in getting there and maintaining this range of motion.

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 helpful. Severe arthritis is usually best managed by either a partial or a complete joint replacement. The ream and run procedure may be considered by patients who are willing to put in substantial extra 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 motivated and committed to work diligently to achieve a shoulder reconstruction that does not require plastic and bone cement.

Who Should Probably Not Consider A Ream And Run?

This procedure is less likely to be successful in individuals with rheumatoid arthritis, depression, obesity, diabetes, Parkinson's disease, multiple previous shoulder surgeries, shoulder joint infections, rotator cuff deficiency and severely altered shoulder anatomy. Patients who 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.

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 or arm 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 of these may need to be modified or stopped before the time of surgery.

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) are often given by injection. Within a day or so oral pain medications (such as hydrocodone or Tylenol with codeine) are usually sufficient. 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 or third day after surgery. Patients are to avoid lifting more than one pound pushing and pulling for six weeks after surgery. Driving is recommended only after the shoulder has regained comfort and the necessary motion and strength. This may take several weeks after surgery. Thus the patient needs to be prepared to have less arm function for the first month or so after surgery than immediately before surgery. For this reason patients usually require some assistance with self-care activities of daily living shopping and driving for approximately six weeks after surgery. Management of these limitations requires advance planning to accomplish the activities of daily living during the period of recovery.

What About Rehabilitation?

Early motion after a ream and run is critical for achieving optimal shoulder function. Arthritic shoulders are stiff. Although a major goal of the surgery is to relieve this stiffness by release of scar tissue it may recur during the recovery process if range of motion exercises are not accomplished immediately. For the first 6 weeks of the recovery phase the focus of rehabilitation is on maintaining the motion that was recovered at surgery. Strengthening exercises are avoided during the first 6 weeks so as not to stress the tendon repair before it heals back to the bone. Later on once the shoulder is comfortable and flexible strengthening exercises and additional activities are started. Some patients prefer to carry out the rehabilitation program themselves. Others prefer to work with a physical therapist who understands the program for the ream and run

When Can Ordinary Daily Activities Be Resumed?

In general patients are able to perform gentle activities of daily living using the operated arm from two to six weeks after surgery. Walking is strongly encouraged. Driving should wait until the patient can perform the necessary functions comfortably and confidently. Recovery of driving ability may take six weeks if the surgery has been performed on the right shoulder because of the increased demands on the right shoulder for shifting gears. With the consent of their surgeon patients can often return to activities such as swimming golf and tennis at six months after their surgery. More vigorous activities can be gradually added back into the patient's lifestyle as tolerated including progressive weight training paddling and skiing.

Once A Shoulder With Ream And Run Procedure Has Successfully Completed The Rehabilitation Program What Activities Are Permissible?

Once the shoulder has a nearly full range of motion strength and comfort we impose no limitation on the activities it can perform. While there are no strict limitations on participation those activities that involve impact (chopping wood contact sports) and those that involve heavy loads (weightlifting) should be resumed gradually to allow the rotator cuff tendons and muscles to regain their strength and flexibility.

What Problems Can Complicate A Ream And Run And How Can They Be Avoided?

Like all surgeries the ream and run operation can be complicated by infection nerve or blood vessel injury fracture instability component loosening and anesthetic complications. Furthermore this is a technically exacting procedure and requires an experienced surgeon to optimize the bony prosthetic and soft tissue anatomy after the procedure. The procedure can fail if the reconstruction is too tight too loose improperly aligned insecurely fixed or if unwanted bone-to-bone contact occurs. The most common cause of failure is a patient's inability to maintain the range of motion achieved at surgery during the healing period which can last up to six months after surgery.

What If A Ream And Run Does Not Yield The Desired Result?

If the shoulder remains stiff and painful despite the patient’s best efforts consideration can be given to a repeat surgical release of the soft tissues (as is performed as a part of the ream and run procedure) or conversion of the ream and run to a total shoulder by the surgical insertion of a plastic glenoid component.

How Many Ream And Run Surgeries Are Done At The University Of Washington?

We currently perform 40-50 of these procedures each year on carefully selected patients from across the United States.

What If The Patient Lives A Long Way Away From Seattle?

Patients often come to Seattle from a long distance for the procedure. We are available by appointment in the Shoulder and Elbow Clinic 4245 Roosevelt Way N.E. Seattle on Mondays and Fridays to evaluate individuals with shoulder arthritis to discuss the procedures that might be most ideally suited for them. We perform surgery on Tuesdays and Wednesdays at the University of Washington Medical Center 1959 NE Pacific St Seattle Washington 206 598-4288. We also see patients at the Eastside Specialty Center 1700 - 116th Ave NE Bellevue Washington 425 646-7777. Patients having a ream and run procedure are usually able to return home three days after the procedure assuming they have mastered their exercises. The staples used to close the skin can be removed by a nurse or physician near the patient's home. Ideally we like to see patients back at six weeks after surgery to assure that satisfactory progress is being made. We request that patients complete questionnaires at 3 6 12 18 and 24 months after surgery so we can track their progress and that the patient obtain and send to us X-rays at 12 and 24 months after surgery if they are unable to return to Seattle for the annual follow-ups. All patients have our personal email and the clinic contact phone numbers to use in contacting us at any time questions arise.

Surgery for Ream and Run at the University of Washington Department of Orthopaedics and Sports Medicine Seattle Washington

If you are interested in making an appointment to discuss this procedure in Seattle you can call 206-598-BONE (2663) to make an appointment. Our clinical center is located in Seattle Washington USA

Conclusion

Frederick A. Matsen III and Winston J. Warme
Shoulder Surgeons
University of Washington
Department of Orthopaedics and Sports Medicine

Patient stories:

• Masters Athlete Magazine (July/August 2008).
• Racquetball Magazine (July/August 2008)
• WSJ.com (September 13 2008)
• Masters Athletes (July/August 2008)

Peer-reviewed Articles:

•  Articles of interest on Ream and Run (PDF) (0.8 MB)
•  Articles of interest on Glenoid Component Failure in Total Shoulder Arthroplasty (PDF) (2.01 MB)
•  Articles of interest on Glenoid - Ream and Run Study (PDF) (2.32 MB)

References:

Boorman R. S. S. Hacker et al. (2001) "A Conservative Broaching and Impaction Grafting Technique for Humeral Component Placement and Fixation in Shoulder Arthroplasty: The Procrustean Method." Techniques in Shoulder & Elbow Surgery. 2(3):166-175.

Clinton J.M. Warme W.J. Lynch J.R. Lippit S.B. Matsen F.A. III. Shoulder Hemiarthroplasty with Nonprosthetic Glenoid Arthroplasty: The Ream and Run. Techniques in Shoulder and Elbow Surgery 10(1):43-52 March 2009.

Clinton J. A. K. Franta et al. (2007). "Nonprosthetic glenoid arthroplasty with humeral hemiarthroplasty and total shoulder arthroplasty yield similar self-assessed outcomes in the management of comparable patients with glenohumeral arthritis." J Shoulder Elbow Surg 16(5): 534-8.

Hacker S. A. R. S. Boorman et al. (2003). "Impaction grafting improves the fit of uncemented humeral arthroplasty." J Shoulder Elbow Surg 12(5): 431-5.

Lynch J. R. A. K. Franta et al. (2007). "Self-assessed outcome at two to four years after shoulder hemiarthroplasty with concentric glenoid reaming." J Bone Joint Surg Am 89(6): 1284-92.

Matsen F. A. 3rd R. T. Bicknell et al. (2007). "Shoulder arthroplasty: the socket perspective." J Shoulder Elbow Surg 16(5 Suppl): S241-7.

Matsen F. A. 3rd J. M. Clark et al. (2005). "Healing of reamed glenoid bone articulating with a metal humeral hemiarthroplasty: a canine model."J Orthop Res 23(1): 18-26.

Matsen F. A. 3rd J. P. Iannotti et al. (2003). "Humeral fixation by press-fitting of a tapered metaphyseal stem: a prospective radiographic study." J Bone Joint Surg Am 85-A(2): 304-8.

Weldon E. J. 3rd R. S. Boorman et al. (2004). "Optimizing the glenoid contribution to the stability of a humeral hemiarthroplasty without a prosthetic glenoid." J Bone Joint Surg Am 86-A(9): 2022-9.

Weldon Edward J III MD; Boorman Richard S MD; Parsons I. M IV MD; Matsen Frederick A III MD Techniques in Shoulder & Elbow Surgery. 5(2):76-89 June 2004. Ream and Run: The Principles and Procedures of Non-Prosthetic Glenoid Arthroplasty With Prosthetic Humeral Hemiarthroplasty.