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Arthroplasty

Arthroplasty

Everything You Need To Know About Arthroplasty Surgery

 

Preparing for Arthroplasty Surgery

 

To be cleared for surgery, you will need to see your primary care physician or internist for a general medical evaluation.

You will also have preoperative visits with your surgeon. You may need to take several types of tests, including blood tests, a cardiogram, a urine sample, and a chest radiograph.

The amount of preparation you need for joint repair surgery is less than for joint replacement surgery.

The latter procedure is more complex, has a higher risk of complications, involves more hospital resources, and requires a longer recuperation period. To ensure that you are adequately prepared for either surgery, make sure you:

  • Understand your procedure by asking questions and voicing any concerns.
  • Write down all your medical information and bring it with you to every doctor’s appointment; this includes your emergency contacts, healthcare providers, medical conditions, medications, allergies, dietary restrictions, insurance coverage, and legal arrangements.
  • Stay healthy or take steps to improve your health before your surgery.
  • Avoid drinking alcohol 48 hours before surgery.
  • Plan for your return home: arrange for someone to pick you up from the doctor’s office or hospital and stay with you after the surgery, and make sure your home is equipped with everything you need to make your recovery as comfortable as possible.

Follow your surgeon’s instructions for what to do in the 24 hours before surgery.

Questions and Answers about Hip Replacement

This publication contains general information about hip replacement. It describes what a hip replacement is, who should have it, and alternatives to surgery. If surgery is required, it explains what the surgery involves, recovery, and rehabilitation. If you have further questions, you may wish to discuss them with your health care provider.

What Is a Hip Replacement?

Hip replacement, or arthroplasty, is a surgical procedure in which the diseased parts of the hip joint are removed and replaced with new, artificial parts. These artificial parts are called the prosthesis. The goals of hip replacement surgery include increasing mobility, improving the function of the hip joint, and relieving pain. According to the Centers for Disease Control and Prevention (CDC), 332,000 total hip replacements are performed in the United States each year.

 

  • Who Should Have Hip Replacement Surgery?
  • What Are Alternatives to Hip Replacement?
  • What Does Hip Replacement Surgery Involve?
  • Is a Cemented or Uncemented Prosthesis Better?
  • What Can Be Expected Immediately After Surgery?
  • How Long Are Recovery and Rehabilitation?
  • What Are Possible Complications of Hip Replacement Surgery?
  • When Is Revision Surgery Necessary?
  • What Types of Exercise Are Most Suitable for Someone With a Total Hip Replacement?
  • What Research Is Being Conducted on Hip Replacement?
  • Where Can People Find More Information About Hip Replacement Surgery?

  • Information Boxes

  • Why Do People Have Hip Replacement Surgery?
  • How to Prepare for Surgery and Recovery

  • Who Should Have Hip Replacement Surgery?

    People with hip joint damage that causes pain and interferes with daily activities despite treatment may be candidates for hip replacement surgery. Osteoarthritis is the most common cause of this type of damage. However, other conditions, such as rheumatoid arthritis (a chronic inflammatory disease that causes joint pain, stiffness, and swelling), osteonecrosis (or avascular necrosis, which is the death of bone caused by insufficient blood supply), injury, fracture, and bone tumors also may lead to breakdown of the hip joint and the need for hip replacement surgery.

    In the past, doctors reserved hip replacement surgery primarily for people over 60 years of age. The thinking was that older people typically are less active and put less stress on the artificial hip than do younger people. In more recent years, however, doctors have found that hip replacement surgery can be very successful in younger people as well. New technology has improved the artificial parts, allowing them to withstand more stress and strain and last longer.

    Today, a person’s overall health and activity level are more important than age in predicting a hip replacement’s success. Hip replacement may be problematic for people with some health problems, regardless of their age. For example, people who have chronic disorders such as Parkinson’s disease, or conditions that result in severe muscle weakness, are more likely than people without chronic diseases to damage or dislocate an artificial hip. People who are at high risk for infections or in poor health are less likely to recover successfully. Therefore they may not be good candidates for this surgery. Recent studies also suggest that people who elect to have surgery before advanced joint deterioration occurs tend to recover more easily and have better outcomes.

    Why Do People Have Hip Replacement Surgery?

    For the majority of people who have hip replacement surgery, the procedure results in:

    • a decrease in pain
    • increased mobility
    • improvements in activities of daily living
    • improved quality of life.

    What Are Alternatives to Hip Replacement?

    Before considering a total hip replacement, the doctor may try other methods of treatment, such as exercise, walking aids, and medication.1 An exercise program can strengthen the muscles around the hip joint. Walking aids such as canes and walkers may alleviate some of the stress from painful, damaged hips and help you to avoid or delay surgery.

    1All medicines can have side effects. Some side effects may be more severe than others. You should review the package insert that comes with your medicine and ask your health care provider or pharmacist if you have any questions about the possible side effects.

    For hip pain without inflammation, doctors usually recommend the analgesic medication acetminophen.

    For hip pain with inflammation, treatment usually consists of nonsteroidal anti-inflammatory drugs, or NSAIDs. Some common NSAIDs are aspirin and ibuprofen.2 When neither NSAIDs nor analgesics are sufficient to relieve pain, doctors sometimes recommend combining the two. Again, this should be done only under a doctor’s supervision.

    2 Warning: Side effects of NSAIDs include stomach problems; skin rashes; high blood pressure; fluid retention; and liver, kidney, and heart problems. The longer a person uses NSAIDs, the more likely he or she is to have side effects, ranging from mild to serious. Many other drugs cannot be taken when a patient is being treated with NSAIDs, because NSAIDs alter the way the body uses or eliminates these other drugs. Check with your health care provider or pharmacist before you take NSAIDs. NSAIDs should only be used at the lowest dose possible for the shortest time needed.

    In some cases, a stronger analgesic medication such as tramadol or a product containing both acetaminophen and a narcotic analgesic such as codeine may be necessary to control pain.

    Topical analgesic products may provide additional relief. Some people find that the nutritional supplement combination of glucosamine and chondroitin helps ease pain. People taking nutritional supplements, herbs, and other complementary and alternative medicines should inform their doctors to avoid harmful drug interactions.

    In a small number of cases, doctors may prescribe corticosteroid medications, such as prednisone or cortisone, if NSAIDs do not relieve pain. Corticosteroids reduce joint inflammation and are frequently used to treat rheumatic diseases such as rheumatoid arthritis. Because of the serious side effects associated with corticosteroids, a doctor must prescribe and monitor treatment.

    Sometimes, corticosteroids are injected into the hip joint.

    If exercise and medication do not relieve pain and improve joint function, the doctor may suggest a less complex corrective surgery before proceeding to hip replacement. One common alternative to hip replacement is an osteotomy. This procedure involves cutting and realigning bone, to shift the weight from a damaged and painful bone surface to a healthier one. Recovery from an osteotomy takes several months. Afterward, the function of the hip joint may continue to worsen and additional treatment may be needed. The length of time before another surgery is needed varies greatly and depends on the condition of the joint before the procedure.

    What Does Hip Replacement Surgery Involve?

    The hip joint is located where the upper end of the femur, or thigh bone, meets the pelvis, or hip bone. A ball at the end of the femur, called the femoral head, fits in a socket (the acetabulum) in the pelvis to allow a wide range of motion.

    During a traditional hip replacement, which lasts from 1 to 2 hours, the surgeon makes a 6- to 8-inch incision over the side of the hip through the muscles and removes the diseased bone tissue and cartilage from the hip joint, while leaving the healthy parts of the joint intact. Then the surgeon replaces the head of the femur and acetabulum with new, artificial parts. The new hip is made of materials that allow a natural gliding motion of the joint.

    In recent years, some surgeons have begun performing what is called a minimally invasive, or mini-incision, hip replacement, which requires smaller incisions and a shorter recovery time than traditional hip replacement. Candidates for this type of surgery are usually age 50 or younger, of normal weight based on body mass index and healthier than candidates for traditional surgery. Joint resurfacing is also being used.

    Regardless of whether you have traditional or minimally invasive surgery, the parts used to replace the joint are the same and come in two general varieties: cemented and uncemented.

    Cemented parts are fastened to existing, healthy bone with a special glue or cement. Hip replacement using these parts is referred to as a “cemented” procedure. Uncemented parts rely on a process called biologic fixation, which holds them in place. This means that the parts are made with a porous surface that allows your own bone to grow into the pores and hold the new parts in place. Sometimes a doctor will use a cemented femur part and uncemented acetabular part. This combination is referred to as a hybrid replacement.

    Is a Cemented or Uncemented Prosthesis Better?

    The answer to this question is different for different people. Because each person’s condition is unique, the doctor and you must weigh the advantages and disadvantages.

    Cemented replacements are more frequently used for older, less active people and people with weak bones, such as those who have osteoporosis, while uncemented replacements are more frequently used for younger, more active people.

    Studies show that cemented and uncemented prostheses have comparable rates of success. Studies also indicate that if you need an additional hip replacement, or revision, the rates of success for cemented and uncemented prostheses are comparable. However, more long-term data are available in the United States for hip replacements with cemented prostheses, because doctors have been using them here since the late 1960s, whereas uncemented prostheses were not introduced until the late 1970s.

    The primary disadvantage of an uncemented prosthesis is the extended recovery period. Because it takes a long time for the natural bone to grow and attach to the prosthesis, a person with uncemented replacements must limit activities for up to 3 months to protect the hip joint. Also, it is more common for someone with an uncemented prosthesis to experience thigh pain in the months following the surgery, while the bone is growing into the prosthesis.

    How to Prepare for Surgery and Recovery

    People can do many things before and after they have surgery to make everyday tasks easier and help speed their recovery.

    Before Surgery

    • Learn what to expect. Request information written for patients from the doctor, or contact one of the organizations listed near the end of this publication.
    • Arrange for someone to help you around the house for a week or two after coming home from the hospital.
    • Arrange for transportation to and from the hospital.
    • Set up a “recovery station” at home. Place the television remote control, radio, telephone, medicine, tissues, wastebasket, and pitcher and glass next to the spot where you will spend the most time while you recover.
    • Place items you use every day at arm’s level to avoid reaching up or bending down.
    • Stock up on kitchen supplies and prepare food in advance, such as frozen casseroles or soups that can be reheated and served easily.

    After Surgery

    • Follow the doctor’s instructions.
    • Work with a physical therapist or other health care professional to rehabilitate your hip.
    • Wear an apron for carrying things around the house. This leaves hands and arms free for balance or to use crutches.
    • Use a long-handled “reacher” to turn on lights or grab things that are beyond arm’s length. Hospital personnel may provide one of these or suggest where to buy one.

    What Can Be Expected Immediately After Surgery?

    You will be allowed only limited movement immediately after hip replacement surgery. When you are in bed, pillows or a special device are usually used to brace the hip in the correct position. You may receive fluids through an intravenous tube to replace fluids lost during surgery. There also may be a tube located near the incision to drain fluid, and a type of tube called a catheter may be used to drain urine until you are able to use the bathroom. The doctor will prescribe medicine for pain or discomfort.

    On the day after surgery or sometimes on the day of surgery, therapists will teach you exercises to improve recovery. A respiratory therapist may ask you to breathe deeply, cough, or blow into a simple device that measures lung capacity. These exercises reduce the collection of fluid in the lungs after surgery.

    As early as 1 to 2 days after surgery, you may be able to sit on the edge of the bed, stand, and even walk with assistance.

    While you are still in the hospital, a physical therapist may teach you exercises such as contracting and relaxing certain muscles, which can strengthen the hip. Because the new, artificial hip has a more limited range of movement than a natural, healthy hip, the physical therapist also will teach you the proper techniques for simple activities of daily living, such as bending and sitting, to prevent injury to your new hip.

    How Long Are Recovery and Rehabilitation?

    Usually, people do not spend more than 3 to 5 days in the hospital after hip replacement surgery. Full recovery from the surgery takes about 3 to 6 months, depending on the type of surgery, your overall health, and the success of your rehabilitation.

    It is important to get instructions from your doctor before leaving the hospital and to follow them carefully once you get home. Doing so will you give you the greatest chance of a successful surgery.

    What Are Possible Complications of Hip Replacement Surgery?

    New technology and advances in surgical techniques have greatly reduced the risks involved with hip replacements.

    The most common problem that may arise soon after hip replacement surgery is hip dislocation. Because the artificial ball and socket are smaller than the normal ones, the ball can become dislodged from the socket if the hip is placed in certain positions. The most dangerous position usually is pulling the knees up to the chest.

    The most common later complication of hip replacement surgery is an inflammatory reaction to tiny particles that gradually wear off of the artificial joint surfaces and are absorbed by the surrounding tissues. The inflammation may trigger the action of special cells that eat away some of the bone, causing the implant to loosen. To treat this complication, the doctor may use anti-inflammatory medications or recommend revision surgery (replacement of an artificial joint). Medical scientists are experimenting with new materials that last longer and cause less inflammation. Less common complications of hip replacement surgery include infection, blood clots, and heterotopic bone formation (bone growth beyond the normal edges of bone).

    To minimize the risk of complications, it's important to know how to prevent problems and to recognize signs of potential problems early and contact your doctor. For example, tenderness; redness and swelling of your calf; or swelling of your thigh, ankle, or foot could be warning signs of a possible blood clot. Warning signs of infection include fever, chills, tenderness and swelling, or drainage from the wound. You should call your doctor if you experience any of these symptoms.

    When Is Revision Surgery Necessary?

    Hip replacement is one of the most successful orthopaedic surgeries performed. However, because more people are having hip replacements at a younger age, and wearing away of the joint surface becomes a problem after 15 to 20 years, replacement of an artificial joint, which is also known as revision surgery, is becoming more common. It is more difficult than first-time hip replacement surgery, and the outcome is generally not as good, so it is important to explore all available options before having additional surgery.

    Doctors consider revision surgery for two reasons: if medication and lifestyle changes do not relieve pain and disability, or if x rays of the hip show damage to the bone around the artificial hip that must be corrected before it is too late for a successful revision. This surgery is usually considered only when bone loss, wearing of the joint surfaces, or joint loosening shows up on an x ray. Other possible reasons for revision surgery include fracture, dislocation of the artificial parts, and infection.

    What Types of Exercise Are Most Suitable for Someone With a Total Hip Replacement?

    Proper exercise can reduce stiffness and increase flexibility and muscle strength. People who have an artificial hip should talk to their doctor or physical therapist about developing an appropriate exercise program. Most of these programs begin with safe range-of-motion activities and muscle-strengthening exercises. The doctor or therapist will decide when you can move on to more demanding activities. Many doctors recommend avoiding high-impact activities, such as basketball, jogging, and tennis. These activities can damage the new hip or cause loosening of its parts. Some recommended exercises are walking, stationary bicycling, swimming, and cross-country skiing. These exercises can increase muscle strength and cardiovascular fitness without injuring the new hip.

    What Research Is Being Conducted on Hip Replacement?

    To increase the chance of surgical success and decrease the risk of complications and prosthesis failure, researchers are working to develop new surgical techniques, more stress-resistant materials, and improved prosthesis designs. They are also looking for ways to reduce the body’s inflammatory response to the artificial joint components.

    Researchers are also studying gender and ethnic discrepancies in those who have the procedure, and characteristics that make some people more likely to have successful surgery.

    Studies are exploring the use of various agents to minimize bone loss around the implant. Strategies to prevent blood clots and implant-related infection are also being investigated.

    Other areas of research address issues of recovery and rehabilitation, such as appropriate postsurgical analgesia for older people, and home-health and outpatient programs.

     

The Knee Arthroplasty

 
 

1. When is the right time to undergo a knee replacement?

There’s no precise formula for determining when you should have a knee replacement. But if you’re having trouble getting up to answer the phone or walk to your car, you may be a candidate. A thorough examination by an orthopedic surgeon should yield a recommendation. It might also be beneficial to receive a second opinion.

2. Is there a way to avoid surgery? 

For some, lifestyle modifications, physical therapy, medication, or alternative treatment methods such as acupuncture and prolotherapy (which involves injecting fluid to strengthen connective tissue) can help manage knee problems. Also, you may want to speak to your surgeon about other procedures that are commonly recommended before resorting to knee replacement surgery, including steroid or hyaluronic acid injections and arthroscopic surgery that addresses the damaged cartilage.

However, delaying or declining a necessary knee replacement could result in a less favorable outcome. Ask yourself: Have I tried everything? Is my knee holding me back from doing the things I enjoy?

3. What will occur during surgery and how long will the knee replacement operation take?

The surgeon will make an incision on the top of your knee in order to expose the damaged area of your joint. The standard incision size can be as long as 10 inches, but a minimally invasive procedure can result in incisions as short as 4 inches. During the operation, the surgeon moves your kneecap aside and cuts away damaged bone and cartilage, which are then replaced with new metal and plastic components. The components combine to form a synthetic (but biologically compatible) joint that mimics the movement of your natural knee. Most knee replacement procedures take 1.5 to two hours to complete. 

4. What pieces are used in a knee replacement and how are they kept in place? 

Implants are comprised of metal and medical-grade plastic. To seal these components to your bone, two methods are used: bone cement, which typically takes about 15 minutes to set; and a cement-less approach that uses components with a porous coating that grows into tissue or attaches to bone. In some cases, a surgeon may use both techniques in the same surgery.

5. Should I be concerned about anesthesia during surgery?

Any surgery with anesthesia has risks. However, complication rates and mortality for general anesthesia are extremely low. An anesthesia team will determine whether general anesthesia or spinal, epidural, or regional nerve block anesthesia is best.

6. How much pain will I experience after surgery?

Although you will experience some pain after surgery, it should diminish quickly—within four or five days max. Your doctor will most likely prescribe medication to help you manage the pain, which will be administered through intravenously (IV) immediately after surgery. After you are released from the hospital, you will switch to painkillers taken in a pill or tablet form. After you have recovered from surgery, you should experience significantly less pain in your knee but there’s no way to predict exact results—some patients have knee pain for a full year after the surgery. Your willingness to engage in physical therapy and make lifestyle modifications can have a significant impact on your post-surgery level of pain and adjustment to the implant.

7. What should I expect immediately following surgery?

You will wake up with a bandage over your knee and, in most cases, a drain to remove fluid from the joint. It is likely that you will wake up with your knee elevated and cradled in a continuous passive motion (CPM) machine that gently extends and flexes your leg while you are lying down. A doctor might also insert a catheter so you don’t have to get out of bed to get to a toilet. In addition, you may wear a compression bandage or sock around your leg to improve blood circulation and reduce the odds of a clot. Your doctor will administer antibiotics intravenously and you may receive anticoagulants (blood thinners) to reduce the odds of a clot. Many patients experience an upset stomach during the immediate post-surgery period—this is normal, and your doctor or nurse can help provid medication to ease stomach pain.

8. What can I expect during recovery and rehabilitation from knee replacement?

Most patients are up and walking within a day or two—with the aid of a walker or crutches. A physical therapist will help you bend and straighten your knee a few hours after your surgery.

After you return home, therapy will continue regularly for weeks and you will be asked to engage in specific exercises designed to improve the functionality of the knee. If your condition is more severe, or if you don’t have the needed support at home, the doctor may recommend you first stay at rehabilitation or nursing facility, though this is rare. During the weeks after surgery, your doctor will wean you from pain medication.

9. What do I need to do to prepare my home for recovery?

If you live in a multiple story house, prepare a bed and space on the ground floor so that you can avoid the stairs when you first return. Make sure the house is free of obstructions and hazards including power cords, area rugs, clutter, and furniture. Focus specially on pathways, hallways, and other places where you are likely to have to walk through. It’s wise to make sure that handrails are secure and a grab bar is available in the tub or shower you plan to use. You may want to add a bath/shower seat.

10. Will I require any special equipment?

Your doctor will likely recommend that you use a CPM machine at home, while lying on a flat surface or bed. You may be sent home from the hospital with this device, but if you aren’t, your doctor or therapist will arrange that one be delivered to you. A CPM machine helps to increase your knee motion during the first few weeks after surgery, and is usually prescribed to slow the development of scar tissue and to help you achieve the maximum range of motion from your implanted knee. It is crucial to use the device as prescribed by your doctor or PT.

Additionally, your doctor will prescribe mobility equipment that you need, like a walker, crutch, etc.

11. What activities will I be able to engage in?

You should be able to resume normal daily activities—such as walking and bathing—within several days. Low impact exercise should also be doable after your rehabilitation period, typically six to 12 weeks. Consult with your physical therapist about introducing new activities during this rehabilitation period. You should avoid running, jumping, bicycling up and down hills and other high impact activities.

12. How long will the artificial knee joint last and will I ever require a revision (a second knee replacement)?

Studies show that upwards of 85 percent of patients still have a functioning artificial joint 20 years after receiving it. However, wear and tear on the joint can adversely affect its performance and lifespan. Younger patients are more likely to have the joint wear out and require a revision during their lifetime. Consult with a doctor about what’s right for you.

 

The Shoulder Arthroplasty

Total Shoulder Arthroplasty involves replacement of the worn out ball with a smooth metal ball. This ball is connected to a metal stem that is placed on the inside of your arm bone (humerus) [FIGURE 1].  The stem is held in place with some of your own bone that is taken from the ball (humeral head).  The socket (glenoid) component is made out of plastic and is held in place with a small amount of bone cement [FIGURE 2].  The final replacement consists of a smooth metal ball moving on a smooth plastic socket.  [FIGURES 3 4 5 & 6]

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FIGURE 1: Humeral component that is used for both Total Shoulder Arthroplasty and the Ream and Run procedure. The stem is titanium and the ball is metal alloy.

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FIGURE 2: Glenoid component that is used for Total Shoulder Arthroplasty only. It is made of a plastic known as polyethylene.

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FIGURES 3: X-rays of a 58 year-old woman with severe osteoarthritis of the shoulder. Note the large bone spurs and absence of joint space.

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FIGURES4: X-rays of a 58 year-old woman with severe osteoarthritis of the shoulder. Note the large bone spurs and absence of joint space.

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FIGURES 5: X-rays of the same woman in Figures 3 & 4 after Total Shoulder Arthroplasty. Note that the bone spurs have been removed and that the humeral component has been placed inside of the arm bone. The plastic glenoid component is not visible on x-ray.

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FIGURES 6: X-rays of the same woman in Figures 3 & 4 after Total Shoulder Arthroplasty. Note that the bone spurs have been removed and that the humeral component has been placed inside of the arm bone. The plastic glenoid component is not visible on x-ray.

 

Not all surgical cases are the same, this is only an example to be used for patient education.

Who should consider Total Shoulder Arthroplasty?

Individuals who want the quickest and most reliable path to a comfortable shoulder should strongly consider Total Shoulder Arthroplasty. Resurfacing the ball with metal and the socket with plastic provides an immediate smooth surface for your shoulder. This means that your shoulder should be quite comfortable within weeks following the surgery.  Although daily exercises are still encouraged they do not have to be quite as rigorous as in individuals who opt for the Ream and Run surgery. If you anticipate having difficulty doing exercises multiple times per day for several months total shoulder arthroplasty may be a better option for you.  Additionally individuals who live sedentary lifestyles smokers diabetics and those who require heavy narcotics for shoulder or other pain are generally better off with a total shoulder arthroplasty than a Ream and Run procedure.

What is the 'Ream and Run' procedure?

The Ream and Run procedure involves replacement of the worn out ball with a smooth metal ball that is connected to a metal stem just like in the total shoulder (below). The stem is placed inside of the arm bone (humerus) and held in place with some of your own bone that is taken from the ball (humeral head). The main difference between a ‘Ream and Run’ and a Total Shoulder Arthroplasty is that with the ‘Ream and Run’ a plastic glenoid component and bone cement are not needed.  Instead the socket (glenoid) is ground down so that it is a smooth shallow cup – a shape that resembles that of the normal socket [FIGURES 7 & 8].  The final replacement consists of a smooth metal ball moving on smooth socket bone. [FIGURES 9 10 11 & 12]  The grinding process allows bone cells to come to the surface of the socket.  These cells can form a new surface that is very similar to the cartilage that normally covers the socket however this process can take 3 to 12 months to occur.

 

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FIGURE 7: The socket (glenoid) before it has been ground down. Note that nearly all of the normal cartilage has been worn away by the disease process.

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FIGURE 8: The socket (glenoid) after it has been ground down so that it is a smooth shallow cup. Note the bleeding bone that will bring in cells to form a new cartilage-like layer.

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FIGURES 9: X-rays of a very active 57 year-old woman with advanced arthritis of the shoulder. Note the bone spurs and absence of joint space.

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FIGURES 10: X-rays of a very active 57 year-old woman with advanced arthritis of the shoulder. Note the bone spurs and absence of joint space.

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FIGURES 11: X-rays of the same woman in Figures 9 & 10 after the Ream and Run procedure. Note that the bone spurs have been removed and that the humeral component has been placed inside of the arm bone. Figure 12 shows space between the metal ball and socket that implies that a new cartilage-like surface has formed.

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FIGURES 12: X-rays of the same woman in Figures 9 & 10 after the Ream and Run procedure. Note that the bone spurs have been removed and that the humeral component has been placed inside of the arm bone. Figure 12 shows space between the metal ball and socket that implies that a new cartilage-like surface has formed.

Who should consider Ream and Run?

Individuals who enjoy strenuous activities such as weightlifting,  waterskiing,  contact sports,  landscaping and chopping wood should strongly consider having a Ream and Run procedure. These activities put a lot of stress on the shoulder joint.  Over time these stresses can wear out or loosen the plastic socket of a Total Shoulder Arthroplasty.  If this occurs it may be necessary to have another surgery to remove the plastic component.  Individuals less than 50 years old may wear out or loosen the plastic glenoid component even with less strenuous activities so they too should consider having a Ream and Run instead of Total Shoulder Arthroplasty.

What aspects of shoulder replacement surgery are the same for Total Shoulder Arthroplasty and Ream and Run?

Regardless of which of the two procedures you choose to have certain aspects of the surgery will be the same. An incision is made across the front of the shoulder from the collarbone to the middle of the arm bone so that the surgeon can gain access to the shoulder without having to cut either the deltoid or the pectoralis major muscles.  One of the four rotator cuff tendons needs to be released to access the shoulder joint.  This tendon (the subscapularis) is repaired at the end of the surgery and takes 3 months to completely heal back to the bone.  The tight soft tissues and bone spurs that have formed as a result of the arthritis need to be released and removed for both procedures.

The metal ball and the stem that is attached to it are the same for both procedures. In both cases the stem is held in place inside your arm bone by bone that has been removed from the arthritic portion of the ball.  This bone supports the metal ball and stem in the proper position.  

For either procedure you usually have a choice of a general anesthetic or a brachial plexus block for your surgery.  The block completely numbs your arm for approximately 12 hours and thus helps keep you comfortable immediately following surgery. When the block wears off the pain comes back and needs to be managed with medication given by mouth or in the IV.

Both procedures take approximately 2 hours to complete.  Typically you will stay in the hospital for 2 nights regardless of which procedure you have done.  Your rehabilitation exercises will start the evening of surgery or the very next morning.  The exercises that you do are the same regardless of which procedure you have done.  However the Ream and Run procedure requires a very strong dedication to the exercises as your shoulder is more likely to get stiff following this procedure than Total Shoulder Arthroplasty.

After either procedure there may be bleeding into the shoulder from cutting the bone. Bone is not in fact ‘dry as a bone’ but has many small blood vessels in it that may leak a bit after surgery. Often a drain is used for a day after surgery to remove this blood.

A study performed here at University of Washington showed Total Shoulder Arthroplasty and Ream and Run are equally likely to provide patients with a comfortable and functional shoulder.  Article on Nonprosthetic Glenoid Arthroplasty (PDF) (0.09 MB).


What aspects of shoulder replacement surgery are different for Total Shoulder Arthroplasty and Ream and Run?

The main difference between the two procedures is in the work that is done on the socket. In Total Shoulder Arthroplasty the socket is resurfaced with a plastic component that is cemented into your bone.  In the Ream and Run no plastic or cement used.  Instead the socket is ground down so that it is smooth and will mate with the smooth metal ball.  The ground down bone bleeds and this bleeding allows bone cells to cover the surface of the socket.  Over time these cells form what is known as fibrocartilage which is similar but not the same as the cartilage that covers the socket in normal shoulders.  

While patients who undergo Ream and Run may ultimately achieve the same level of comfort and function as those who undergo Total Shoulder Arthoplasty it may take some patients longer to reach this level.  Some patients achieve it just as quickly as those who undergo Total Shoulder Arthroplasty some take up to 12 months to achieve this level and a few never achieve the same level of comfort that they would with Total Shoulder Arthroplasty. Article on Nonprosthetic Glenoid Arthroplasty (PDF) (0.09 MB).

Because the Ream and Run relies on the bone cells to form fibrocartilage certain individuals are not good candidates for the procedure.  Smokers and patients with diabetes do not have the robust bone cells that are necessary for this healing to take place and are thus better off with a Total Shoulder Arthroplasty

What happens if my Total Shoulder Arthroplasty fails?

The most likely way that Total Shoulder Arthroplasty fails is by loosening or wear of the plastic glenoid component. If this occurs a second surgery is necessary to remove the loose component.  It is usually not possible to place a new plastic component because there is typically not enough bone remaining to support it.   If that is the case we usually try to smooth the remaining bone so that it can accommodate the metal ball.  Surprisingly many patients have very good comfort and function following such an operation.

What happens if my Ream and Run fails?

Although most patients have very good return of comfort and function to their shoulder following the Ream and Run a few never get the type of pain relief that they had hoped for. It is difficult to predict who will fall into this category but in our experience it is fewer than 1 in 20 patients. These patients are often those who found it difficult to maintain their range of motion after surgery. It is possible to go in via a second surgery either to release the soft tissues to restore the range of motion or to place a plastic glenoid component in essence converting the Ream and Run to a Total Shoulder Arthroplasty.  Most of the work has already been done with the first operation so the recovery is not quite as long as with the first surgery.

Credits & Documentation references

 

 
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