Ream and Run non-prosthetic glenoid arthroplasty for shoulder arthritis: Regenerative cementless surgery designed for individuals desiring higher levels of activity than recommended for traditional total joint replacement.
Edited By: Frederick A. Matsen III, M.D., Winston J. Warme, MD
Last updated Wednesday, October 28, 2009
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Figure 1 - Humeral head that has been damaged by arthritis.
Figure 2 - Artificial components of a shoulder replacement.
Figure 3 - Glenoid bone spurs: The figure on the left shows bone spurs at the bottom of the joint. The figure on the right shows that the ball is not centered and has worn down the back part of the socket.
Figure 6 - Humeral implant
Figure 7 - Humeral Cut: the amount of the damaged ball that is removed.
Figure 8 - Glenoid bone being reshaped with a spherical reamer.
Figure 9 - Axillary incision
Figure 10 - Axillary incision
Figure 12 - Arthritic glenoid
Figure 13 - Arthritic glenoid after it has been reamed
Figure 14 - Continuous passive motion machine
Summary
Overview
Non-prosthetic glenoid arthroplasty, sometimes called the "ream and run" procedure, is a surgical treatment that can help relieve the pain from severe arthritis of the shoulder. Unlike conventional "metal on plastic" total shoulder replacement (total shoulder arthroplasty), the "ream and run" approach may allow active patients to remain involved in fitness, recreational, and vocational pursuits that would risk premature failure if traditional total shoulder arthroplasty were to be performed.
The shoulder is a ball and socket joint that allows the arm to be placed in an incredibly wide range of positions during every day activities. The ball is formed by the head of the humerus (arm bone), and the socket is formed by the scapula (shoulder blade). The socket is also referred to as the glenoid. The surfaces of the ball and socket are formed by cartilage, a tissue that allows joints to glide in a smooth and frictionless way.
Arthritis of the shoulder is a condition in which the cartilage on the humeral head and glenoid deteriorates. As this process becomes more advanced, the joint surfaces become rough, and areas of bone may be exposed. Figure 1 shows the surface of a humeral head destroyed by arthritis. Motion of the arthritic joint causes the surfaces to grate rather than glide. Progressive joint destruction makes the shoulder stiff, painful and unable to carry out its normal functions.
When pain and loss of function become disabling enough for a patient to consider treatment, joint replacement surgery is the most reliable solution for shoulder arthritis. The goals of shoulder replacement are to restore comfort and function to the joint by removing scar tissue, balancing muscles, and replacing the destroyed joint surfaces with artificial ones.
The artificial components of a typical shoulder replacement include the humeral ball (which is made of metal) and the glenoid component (which is made of plastic). These are depicted in figure 2. The humeral ball is fixed to the humerus (arm bone) by attachment to a stem that rests securely inside the hollow canal of the bone. The glenoid component is fixed to the shoulder blade using a small amount of bone cement.
While total shoulder replacement surgery has proven to be a successful treatment for advanced shoulder arthritis, the artificial components are not designed to withstand some of the demands that active individuals expect to place on them once comfort and function have been restored. As more and more people continue participation in sports and other recreational activities into their older years, they may slowly begin to exceed the limits of what the artificial components can tolerate.
This is particularly true for the plastic socket that is prone to wear out, loosen or even break in very active individuals. Patients who intend to return to activities that place physical demands on the shoulder replacement (such as golf, tennis, skiing, weightlifting etc.) may therefore be at risk for eventual failure of the artificial shoulder socket. When failure of the socket occurs, patients typically experience a dramatic decrease in their comfort and function.
Therefore, a conventional total shoulder replacement, which resurfaces the arthritic socket with a plastic component, may not be the best option in terms of preserving comfort and function in very active patients. In these patients, an alternative that removes the destroyed cartilage and provides a smooth and stable surface without insertion of the plastic socket may be more sensible.
This alternative is referred to as shoulder hemiarthroplasty with non-prosthetic glenoid arthroplasty. In this procedure, the humeral head is replaced with a metal ball in the exact same manner as a regular shoulder replacement. The socket is not replaced but is refinished in way that gives it a smooth surface and a shape which matches that the humeral ball. This process can also reorient the direction of the socket when it is pointing too far toward the back as a result of bone erosion.
Because the socket side of the joint is reshaped and the ball side replaced, the rough arthritic surfaces are eliminated from both sides of the shoulder joint. By avoiding the use of a plastic socket, non-prosthetic glenoid arthroplasty removes the risk of loosening or wear of the polyethylene component Because problems with the metal ball are very rare, this procedure should improve the longevity of comfort and function in patients who might otherwise experience earlier problems related to socket loosening or wear.
This procedure has proven successful in restoring comfort and a high level of shoulder function in patients with severe shoulder arthritis. The recovery of comfort may take longer than with conventional total shoulder arthroplasty, however. Like a conventional shoulder replacement operation, it is a highly technical procedure and is best performed by a surgical team who performs this surgery often. Such a team can maximize the benefit and minimize the risks. The two-hour procedure is performed under general (or nerve block) anesthesia.
Shoulder motion is started immediately after the procedure. Patients learn to do their own physical therapy and are usually discharged three days after surgery if they are comfortable and have a good range of passive motion. The recovery of strength and function may continue for up to a year after surgery.
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Characteristics of arthritis of the shoulder
Arthritis of the shoulder is a condition in which the cartilage normally covering the joint surfaces is lost.
Individuals with shoulder arthritis usually notice pain, stiffness
and loss of the ability to use the shoulder for their usual activities.
Commonly, they have difficulty sleeping on the affected shoulder and
limited range of motion. Some people with arthritis notice a grinding
feeling when the shoulder is moved. Shoulder arthritis usually gets
worse over time, but the rate of this progression varies widely.
Types
Shoulder arthritis may be of several types, including osteoarthritis (or degenerative joint disease), rheumatoid arthritis, arthritis after injury (traumatic arthritis), arthritis after previous surgery (for example, capsulorrhaphy arthropathy), and arthritis associated with rotator cuff disease (known as cuff tear arthropathy). Arthritis may also follow infection; this is known as septic arthritis. If the ball of the shoulder joint (humeral head) dies from lack of circulation, a condition known as avascular necrosis (or osteonecrosis) of the shoulder may result.Similar conditions
Shoulder arthritis must be distinguished from rotator cuff disease,
frozen shoulder, and neck arthritis, each of which may produce similar
symptoms. Rotator cuff tears usually cause pain and weakness, but
stiffness is less common. Frozen shoulder is characterized by shoulder
stiffness, but the X-rays are usually normal. Neck arthritis may cause
shoulder pain and weakness that is worse when the head is held in
certain positions.Incidence and risk factors
Although not as common as rotator cuff disease, shoulder arthritis is
among the most prevalent causes of shoulder pain and loss of function.
Arthritis of the shoulder joint is less common than arthritis of the
hip or knee. Individuals with arthritis in one joint are more likely to
get it in another joint.Diagnosis
A physician diagnoses shoulder arthritis by reviewing the patient's
history, performing a thorough physical examination of the joint and
taking the proper X-rays. The examination of an arthritic shoulder
reveals stiffness and roughness of the joint.
X-rays of the shoulder reveal the contour of the joint surfaces and
the status of the cartilage space between them. X-rays of an arthritic
shoulder usually show a narrowing of the space between the ball and
socket--often to the point that bone is touching bone. The left side of
figure 3 shows bone spurs at the bottom of the joint. The right side of
figure 3 shows that the ball is not centered and has worn down the back
part of the socket. These findings indicate that the normal cartilage
has been destroyed. X-rays do not show the soft tissues, such as scar
tissue, that may also be limiting joint motion.
It is essential that the shoulder surgeon establish the diagnosis of arthritis before shoulder joint replacement is considered.
Medications
Medications may be helpful in managing arthritis. In the case of
rheumatoid arthritis, specific drugs may treat the inflammation that
destroys the cartilage. Some of these medications are administered by
injection and others by mouth. Some individuals take anti-arthritic
medications for their entire lives. These medications can be quite
helpful, but there may be side effects. These medications should be
taken under the close supervision of a rheumatologist or other
physician experienced in their use. In other types of arthritis,
anti-inflammatory drugs may lessen the pain, but do not change the
course of the condition. It is important that the patient be aware of
the possible side effects of these medications, including stomach
irritation, kidney problems and bleeding. Injections of steroids
(cortisone) or lubricants (such as hyaluronic acid) into the shoulder
have not been demonstrated to have lasting benefit and carry some risk
of infection.
For each medication, patients should learn:
- the risks,
- possible interactions with other drugs,
- the recommended dosage, and
- the cost.
Exercises
If exercises are not too painful, they may be helpful in maintaining
the flexibility and strength of joints with arthritis. In most cases
these exercises can be done in the patient's home with minimal
equipment. Shoulder exercises are best performed gently several times a
day on an ongoing basis. Often the exercises will help during the
earlier phases of the condition. The exercises are not dangerous if
they are performed gently. The diagrams show two examples of these
exercises.
Figure 4 shows a patient using the left arm to help lift the stiff
right shoulder in a forward direction. Figure 5 shows a patient using
the left arm to gently stretch the stiff right arm in external rotation
using a yardstick.
Sometimes other types of therapy are used by physical therapists.
Patients should learn the possible risks of these approaches as well as
their costs and anticipated effectiveness.
Possible benefits of non-prosthetic glenoid arthroplasty
With proper rehabilitation, shoulder hemiarthroplasty with
non-prosthetic glenoid arthroplasty restores lost function to arthritic
shoulder joints. By removing the damaged joint surfaces, this procedure
allows the shoulder to move in a smooth and stable manner. In
experienced, hands, this procedure can also address the restricting
scar tissue that frequently accompanies arthritis and contributes to
pain and stiffness.
Both total shoulder replacement surgery and non-prosthetic glenoid
arthroplasty can improve the mechanics of the shoulder, but cannot make
the joint as good as it was before the onset of arthritis. In many
cases, the tendons and muscles around the shoulder have been weakened
from prolonged disuse before the operation. It can often take months of
gentle exercises before the shoulder achieves maximum improvement.
The effectiveness of the procedure depends on the health and
motivation of the patient, the condition of the shoulder, and the
expertise of the surgeon. Strict adherence to the rehabilitation
program maximizes the chances of a good result from non-prosthetic
glenoid arthroplasty. Maintaining general health, fitness and nutrition
as well as abstinence from cigarette smoking all improve the chances of
success. The greatest improvements are in the ability of the patient to
sleep, to perform activities of daily living, and to perform
non-contact recreational activities.
Types of surgery recommended
When the normally smooth surfaces of the shoulder joint are severely
damaged by arthritis or injury, shoulder replacement surgery is the
most effective method for restoring comfort and function to the joint.
There are other surgical options for treatment of arthritis of the
shoulder, but none have proven as effective in terms of pain relief and
patient satisfaction as shoulder replacement. Arthroscopy or "clean up"
operations have not been shown to give lasting benefit. Shoulder fusion
can stabilize the joint, but does not allow shoulder motion. Removing
the joint allows some motion at the joint, but does not provide
stability.Who should consider non-prosthetic glenoid arthroplasty?
Joint replacement surgery is considered when:
- the arthritis is a major problem for the patient,
- the patient is sufficiently healthy to undergo the procedure,
- the patient understands and accepts the risks and alternatives,
- there is sufficient bone and tendon to permit the surgery, and
- the surgeon is experienced in shoulder replacement surgery.
What happens without surgery?
The natural history of arthritis is that it usually continues to
progress over time. The rate of progression varies between individuals
and is unpredictable. Sometimes the pain and stiffness from shoulder
arthritis will stabilize at a level that is acceptable and manageable
to the patient. In general, this surgery is elective, and can be
performed whenever the patient decides that the arthritis has become
disabling enough to warrant treatment. Delaying surgery typically does
not compromise the success of surgery in the future. However, in cases
of rheumatoid arthritis, excessive delay may result in loss of the
tendon and bone, making the surgery more difficult for the patient and
for the surgeon.
Surgical options
Several types of shoulder arthroplasty are used to manage arthritis.
In total shoulder arthroplasty, the surfaces of both the humeral head
(ball) and the glenoid (socket) are resurfaced with metal and plastic
implants. Figure 6 shows the metal humeral ball and humeral stem as
well as the plastic glenoid prosthesis. In shoulder hemiarthroplasty, a
prosthesis is used only on the humeral side of the joint. Because the
humeral component can usually be secured by a press fit, most humeral
replacement surgery does not require bone cement. As a result, the risk
of cement failure is eliminated. Figure 7 shows the amount of the
damaged ball that is removed (humeral cut). In shoulder
hemiarthroplasty with non-prosthetic glenoid arthroplasty, the humeral
surface is replaced and the glenoid socket is reshaped. Figure 8 shows
the glenoid bone being reshaped with a spherical reamer.
The decision about which type of shoulder replacement will maximize
benefit and minimize risk depends on several factors. These include the
location and severity of the arthritis, the age of the patient and the
level of physical demand the patient expects to exert on the replaced
shoulder. When advanced arthritis has destroyed both the ball and
socket, then both sides of the joint must be addressed.
As with joint replacement procedures in other parts of the body, the
plastic components used in the replacement do not last forever. Much
like the brakes of a car wear out with use, the plastic socket used in
total shoulder replacement surgery tends to wear with time. The process
can take the form of flattening, loosening or breaking. In each case,
the socket is no longer able to provide a smooth and stable foundation
for the ball. Patients will often note that their comfort and function
decline as the socket begins to fail. If the socket breaks, patients
often notice an immediate increase in pain with shoulder use.
It stands to reason that younger and more active patients are more
likely to experience socket wear in the course of their life as the
plastic is exposed to a longer period of use. In addition, patients who
remain physically active often place higher demands on the shoulder. As
more people continue to engage in sports and other demanding
recreational activities into their 60’s, 70’s and
80’s, shoulder replacements are being asked to tolerate more wear
and tear – often the same level of use that may have predisposed
the shoulder to develop arthritis in the first place.
Younger patients and those who intend to return to a high level of
physical activity are at risk of developing socket failure after total
shoulder arthroplasty. In certain cases, this can occur within the
first several years after surgery. When failure occurs, additional
surgery is usually required to remove the damaged socket. If the bone
underneath the socket has also been damaged by the wear and loosening
process, it may be impossible to replace the socket. In this case, the
success of revision surgery is less predictable.
Effectiveness
Non-prosthetic glenoid arthroplasty addresses the risk of socket
failure in younger and physically demanding patients. Because no
plastic is inserted into the joint, there are no problems related to
artificial socket wear, loosening and breaking. In the hands of
experienced surgeons, this procedure has proven durable in terms of
allowing patients to return to their expected level of activity. Some
patients who have undergone this procedure have returned to
weightlifting, water-skiing, golf and landscaping. As long as the
shoulder is cared for properly and subsequent injuries are avoided, the
benefit can last for decades.
Shoulder replacement surgery is most effective when the patients are
well motivated and follow a simple exercise program after surgery.
Thus, the patient's motivation and dedication are important elements of
the partnership. Especially after non-prosthetic glenoid arthroplasty,
the need for patience is essential during the early phase of the
rehabilitation while the shaped glenoid surface is healing.
Urgency
Shoulder hemiarthroplasty with non-prosthetic glenoid arthroplasty
is an elective procedure that can be scheduled when circumstances are
optimal for the patient. It is not an urgent procedure. The patient has
plenty of time to become informed and to select and experienced
surgeon.
Factors that the patient should consider in choosing the optimal time include the following:
- The arthritis has become sufficiently disabling to impair the
performance of daily activities. Patients who are still able to sleep
comfortably and manage daily activities may consider waiting.
- A planned period of time can be specifically dedicated to the
recovery and rehabilitation process that will not interfere with other
scheduled events.
- Overall health and nutritional status are optimal and will not
limit the ability to comply with the performance of rehabilitation.
- Motivation and readiness to undertake the process of surgery, recovery and rehabilitation is a priority.
Risks
The risks of shoulder hemiarthroplasty with non-prosthetic glenoid
arthroplasty include but are not limited to the following: infection,
injury to nerves and blood vessels, fracture, stiffness or instability
of the joint, failure of the rotator cuff, pain, and the need for
additional surgeries. There are also risks to anesthesia and blood
transfusion (although transfusions are not always necessary).
Furthermore, it is possible that the joint will remain or become
painful without plastic resurfacing of the glenoid. In such a case, it
may be necessary to revise the hemiarthroplasty to a total shoulder
arthroplasty.
An experienced shoulder joint replacement team will use special
techniques to minimize these risks, but cannot totally eliminate them.
Managing risk
Many of the risks of this surgery can be effectively managed if they
are promptly identified and treated. Infections may require a "wash
out" in the operating room; occasionally removal of the artificial
components is necessary. Blood vessel or nerve injury may require
repair. Fracture may require surgical fixation. Stiffness or
instability may require exercises or additional surgery. If the patient
has questions or concerns about the course after surgery, the surgeon
should be informed as soon as possible.
Preparation
Shoulder hemiarthroplasty with non-prosthetic glenoid arthroplasty
is considered for young and physically active individuals in whom
arthritis interferes with shoulder function.
The success of surgery depends on a partnership between the patient
and the experienced shoulder surgeon. Patients should optimize their
health so that they will be in the best possible condition for this
procedure. Smoking should be stopped a month before surgery and not
resumed for at least three months afterwards. Any heart, lung, kidney,
bladder, tooth, or gum problems should be managed before surgery. Any
infection may be a reason to delay the operation. The shoulder surgeon
needs to be aware of all health issues, including allergies and the
non-prescription and prescription medications being taken. Some of
these may need to be modified or stopped. For instance, aspirin and
anti-inflammatory medication may affect the way the blood clots. Since
blood transfusion may be necessary, patients may choose to have a blood
bank draw and store their own blood.
Figure 9 shows the incision used for a shoulder replacement. This area of skin must be clean and free from sores and scratches.
Before surgery, patients should consider the limitations,
alternatives and risks of surgery. Patients should also recognize that
the result of surgery depends in large part on their efforts in
rehabilitation after surgery.
The patient needs to plan on being less functional than usual for
six to twelve weeks after the procedure. Driving, shopping and
performing usual work or chores may be difficult during this time.
Plans for necessary assistance need to be made before surgery. For
individuals who live alone or those without readily available help,
arrangements for home help should be made well in advance.
Timing
Shoulder hemiarthroplasty with non-prosthetic glenoid arthroplasty
can be delayed until the time that is best for the patient's overall
well being. However, in cases of rheumatoid or other types of
inflammatory arthritis, excessive delays can result in the loss of bone
and tendon tissue. These losses can compromise the quality of the
surgery and its result.
Costs
The surgeon's office should provide a reasonable estimate of:
- the surgeon's fee, and
- the hospital fee.
Surgical team
Shoulder hemiarthroplasty with non-prosthetic glenoid arthroplasty is a
technically demanding procedure that should be performed by an
experienced surgeon in a medical center accustomed to performing
shoulder joint replacements at least several times a month. Patients
should inquire as to the number of shoulder replacement procedures that
the surgeon performs each year and the number of these procedures
performed in the medical center each year.Finding an experienced surgeon
Because only a few thousand shoulder replacement procedures are
performed in the United States each year, it is unlikely that every
community has an experienced shoulder arthroplasty surgeon who performs
many of these procedures each year. The number of surgeons performing
non-prosthetic glenoid arthroplasty as described here is small.
Surgeons specializing in shoulder joint replacement may be located
through university schools of medicine, county medical societies, or
state orthopedic societies. Other resources include local
rheumatologists or professional societies such as the American Shoulder and Elbow Surgeons Society.
Facilities
Shoulder replacement arthroplasty is usually performed in a major
medical center that performs these procedures on a regular basis. These
centers have surgical teams and facilities specially designed for this
type of surgery. They also have nurses and therapists who are
accustomed to assisting patients in their recover from shoulder
replacement surgery.Technical details
Shoulder hemiarthroplasty with non-prosthetic glenoid arthroplasty
is a highly technical procedure; each step plays a critical role in the
outcome.
After the anesthetic has been administered and the shoulder is
prepared, an incision is made across the front of the shoulder from the
middle of the collarbone to the middle of the arm bone as shown in
Figure 10. This incision allows access to the joint without damaging
the important deltoid or pectoralis muscles that are responsible for a
significant portion of the shoulder's power.
The muscles and other tissues near the shoulder are mobilized by
removing any scar tissue that may restrict their motion. The tendon of
the subscapularis muscle is cut to gain access to the joint and
released circumferentially (a 360-degree release) to restore its length
and mobility. Figure 11 shows where the arthritic humeral head (ball of
the joint) is removed. The bone spurs are removed to prepare the bone
for the humeral prosthesis.
The humeral implant is chosen by trialing different sizes and
selecting the one that best matches the patient's anatomy and best
restores the muscle balance in the joint without making the joint too
tight or too loose. The arthritic glenoid is then refinished using a
special spherical reamer. This reaming process corrects the shape and
orientation of the socket, both of which are affected by shoulder
arthritis. The curvature of the reamer nearly matches that of the
humeral ball and this matching surface allows smooth and stable
rotation of the ball in the socket. Figure 12 shows the arthritic
glenoid and figure 13 shows the glenoid after it has been reamed.
In this procedure, the glenoid shape and orientation are corrected,
but a glenoid prosthesis is not inserted. Once the reaming process is
completed, the final humeral component is inserted. The subscapularis
tendon is then carefully repaired and closure of the muscle and skin
layers completes the procedure. A drain is placed which is removed on
the second morning after surgery. This prevents blood from collecting
in the wound.
Anesthetic
Shoulder replacement surgery may be performed under a general
anesthetic or under a brachial plexus nerve block. A brachial plexus
block can provide anesthesia for several hours after the surgery. The
patient may wish to discuss their preferences with the anesthesiologist
before surgery.Length of non-prosthetic glenoid arthroplasty
The procedure usually takes approximately two hours, however the
preoperative preparation and the postoperative recovery may add several
hours to this time. Patients often spend two hours in the recovery room
and two to four days in the hospital after surgery.Pain and pain management
After the non-prosthetic glenoid arthroplasty, the reamed glenoid
surface must heal. This process may require up to a year to complete.
Thus, recovery of comfort and function after shoulder hemiarthroplasty
with non-prosthetic glenoid arthroplasty continues for the first year
after surgery. The rehabilitation is carried out largely by the patient
under the supervision of the surgeon.
Shoulder replacement of this type 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.
Because a plastic socket is not inserted when a non-prosthetic
glenoid arthroplasty is performed, there may be some initial added
discomfort from the metal ball articulating with the bone. When the
glenoid is reamed, small fractures in the surface bone are
intentionally created. These tiny surface fractures initiate a healing
response that improves the smoothness of the socket and may help
distribute force from the arm to the body. This healing process may
make the first 6 weeks more uncomfortable than a total shoulder
replacement surgery. This discomfort should be only temporary and, as
the healing process completes, comfort levels are expected to approach
that of total shoulder arthroplasty.
Use of medications
Initially pain medication is usually administered intravenously or
intramuscularly. Sometimes patient controlled analgesia (PCA) is used
to allow the patient to administer the medication as it is needed.
Hydrocodone or Tylenol with codeine are taken by mouth. Intravenous
pain medications are usually needed only for the first day or two after
the procedure. Oral pain medications are usually needed only for the
first two weeks after the procedure.Effectiveness of medications
Pain medications can be very powerful and effective. Their proper use
lies in the balancing of their pain relieving effect and their other,
less desirable effects. Good pain control is an important part of the
postoperative management.Important side effects
Pain medications can cause drowsiness, slowness of breathing,
difficulties in emptying the bladder and bowel, nausea, vomiting and
allergic reactions. Patients who have taken substantial narcotic
medications in the recent past may find that usual doses of pain
medication are less effective. For some patients, balancing the benefit
and the side effects of pain medication is challenging. Patients should
notify their surgeon if they have had previous difficulties with pain
medication or pain control.Hospital stay
After surgery the patient spends an hour or so in the recovery room and
is then transferred to a private room. A drainage tube is usually used
to remove excess fluid from the surgical area. The drain is usually
removed on the second day after surgery. Bandages cover the incision.
They are usually changed the second day after surgery.
Patients are discharged as soon as the incision is dry, the shoulder is
comfortable with oral pain medications, the patient can perform the
range of motion exercises, and the home support systems for the patient
are in place. Discharge is usually on the third or fourth day after
surgery.Recovery and rehabilitation in the hospital
Early motion after shoulder hemiarthroplasty with non-prosthetic
glenoid arthroplasty helps achieve the best possible shoulder function.
Arthritic shoulders are stiff. Early motion is facilitated by the
complete surgical release of the tight tissues so that after surgery
the patient has only to maintain the range of motion achieved at the
operation. However, after surgery, scar tissue will tend to recur and
limit movement unless motion is started immediately. Early motion also
facilitates healing of the glenoid bone and ensures that a smooth bony
surface will form to articulate with the metal ball.
A continuous passive motion (CPM) machine is often used to gently
move the shoulder in the recovery room immediately after surgery. The
CPM machine, shown in figure 14, is used for the first few days after
surgery whenever the patient is in bed.
During the hospitalization, the patient learns a simple
rehabilitation program that will be used for maintaining the range of
motion at home after discharge. Figures 15 and 16 show the exercises
used to maintain elevation and rotation of the arm. On the day of
surgery or on the day after, the physical therapist teaches the patient
gentle range of motion exercises. The patient is usually shown how to
stretch the shoulder forward and out to the side, preventing stiffness
and adhesions.
Walking and use of the arm for gentle activities are encouraged soon after surgery.
Hospital discharge
At the time of discharge, the patient should be relatively
comfortable on oral medications, should have a dry incision, should
understand their exercises and should feel comfortable with the plans
for managing the shoulder. For the first month or so after this
procedure, the operated arm may be less useful than it was immediately
beforehand.
The specific limitations can be specified only by the surgeon who
performed the procedure. It is important that the repaired tendons not
be challenged until they have had a chance to heal. Usually the patient
is asked to lift nothing heavier than a cup of coffee for six weeks
after the surgery.
Management of these limitations requires advance planning to
accomplish the activities of daily living during the period of recovery.
Convalescent assistance
Patients usually require some assistance with self-care, activities
of daily living, shopping and driving for approximately six weeks after
surgery. Patients usually go home after this surgery, especially if
there are people at home who can provide the necessary assistance, or
if such assistance can be arranged through an agency. In the absence of
home support, a convalescent facility may provide a safe environment
for recovery.
Recovery of comfort and function after shoulder hemiarthroplasty
with non-prosthetic glenoid arthroplasty continues for many months
after the surgery. Improvement in some activities may be evident as
early as six weeks. With persistent effort, patients make progress for
as long as a year after surgery.
Physical therapy
Early motion after shoulder hemiarthroplasty with non-prosthetic
glenoid arthroplasty 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
instituted 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.
Rehabilitation options
It is often most effective for the patient to carry out their own
exercises so that they are done frequently, effectively and
comfortably. Usually, a physical therapist or the surgeon instructs the
patient in the exercise program and advances it at a rate that is
comfortable for the patient.
Structured outpatient physical therapy is usually not necessary
during the initial phase of recovery as the gentle stretching exercises
are more effectively performed by the patient. When strengthening
exercises are added to the program--often at around 6 weeks--outpatient
physical therapy for rotator cuff strengthening may be beneficial.
However, motivated patients may also perform these exercises at home
with equal effectiveness. Occasional visits to the surgeon or therapist
may be useful to check the progress and to review the program.
Usual response
Patients are almost always satisfied with the increases in range of
motion, comfort and function that they achieve with the exercise
program. If the exercises are uncomfortable, difficult, or painful, the
patient should contact the therapist or surgeon promptly.
Risks
This is a safe rehabilitation program with little risk.Duration of rehabilitation
Once the range of motion and strength goals are achieved, the exercise
program can be cut back to a minimal level. However, gentle stretching
is recommended on an ongoing basis. In addition, a maintenance program
to keep the rotator cuff muscles strong and healthy will ensure proper
function of the artificial joint and may help prolong its benefit.Returning to ordinary daily activities
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.
Long-term patient limitations
One of the primary goals of shoulder hemiarthroplasty with
non-prosthetic glenoid arthroplasty is to allow physically demanding
individuals to return to activities that would otherwise have been
prohibited with the implantation of a plastic socket. While there are
no strict limitations on participation, those activities that involve
impact (chopping wood, contact sports) and those that involve heavy
loads (weightlifting) may predispose the rotator cuff tendons to injury
and tear. Thus patients should take caution in these types of
activities to minimize the risk of damage to the operated shoulder.
Costs
The surgeon and therapist should provide the information on the
usual cost of the rehabilitation program. The program is quite
cost-effective, because it is based heavily on home exercises.
Summary of non-prosthetic glenoid arthroplasty for arthritis of the shoulder
Shoulder hemiarthroplasty with non-prosthetic glenoid arthroplasty
helps restore comfort and function to shoulders damaged by degenerative
joint disease and osteoarthritis. This procedure provides an approach
to treating arthritis in young and physically demanding patients whose
arthritis has advanced to the point of surgical treatment. By
reshaping, reorienting and smoothing the bony socket, this procedure
removes the risks associated with wear, loosening and fracture of the
plastic socket.
In the hands of an experienced surgeon, shoulder hemiarthroplasty
with non-prosthetic glenoid arthroplasty can be an effective method for
treating shoulders with damaged joint surfaces in a healthy and
motivated patient. Pre-planning and persistent rehabilitation efforts
will help assure the best possible result for the patient.
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., 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.
Surgery for Arthritis of the Shoulder 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 request an appointment using our online referrals website. To request a referral online, please click here. You can also call 206-598-BONE (2663) to make an appointment. Our clinical center is located in Seattle Washington, USA