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A Surprising Patient

By John Hakon Williksen, MD

Just after I had obtained my specialty in orthopaedic surgery, I also specialized in rheumatoid surgery. This was before “the biologics,” so there were still patients to operate.

The patient I am going to tell about was an elderly lady with a really bad right shoulder with pain, restricted range of movement (ROM), and rheumatoid joint destruction being a good candidate for a total shoulder. As we had just started up to do reversed shoulder prosthesis, I thought why not, since there was a good chance that her ROM would increase.

The operation started out well and I got a good access to the glenoid. In preparing the glenoid for the plate and head, one had to ream and make a good base for the prosthesis. I used a power reamer and started in good spirits – this seemed to go well.

However, after a short time, when I withdrew the reamer, my assistant asked perhaps a little sarcastically: “John, where did the glenoid go?”

I looked down and saw no more glenoid, just the rest of the scapula.

I admit that for a couple of seconds I was bewildered and in despair, thinking of a colleague of mine, a general surgeon who had lost the prostate somewhere in the small pelvis during an open prostatectomy and never retrieved it.

Quickly, I pulled myself together: “Oh, the glenoid,” I said. “It’s gone. It happens sometimes in rheumatoids. Now, I think we just go on and put in a hemi. She will be happy.”

The rest of the procedure went well, but in my mind I was not too happy about this incident.

However, after three months, she visited me in my clinic, telling me: “Doctor, you should really have had a gold medal for this operation.” Her pain was gone and she was happy.

Well, sometimes we are lucky and our results can be good even when we make mistakes, but I would not count on that. I learned a few things: to be careful with powerful instruments and that, in rheumatoid patients, the most important aspect of our treatment is to relieve their pain.

It was a mistake to even think about using a reversed prosthesis in this patient because her bone quality was osteoporotic after several years of cortisone treatment, and using a power reamer in this situation made the glenoid a lost case.

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