**8.2 Subscapularis rupture**

Despite the added security afforded by lesser tuberosity osteotomy, failure can still occur if undue stress is placed on the repair. While the contention maintains that lesser tuberosity

Humeral Hemiarthroplasty with Spherical Glenoid

years postoperatively.

Reaming: Theory and Technique of The Ream and Run Procedure 599

The author currently performs the Ream and Run procedures in roughly 8% of all arthroplasty cases. Generally, it is reserved for male patients aged 65 or less who meet the criteria previously discussed and who understand and accept the longer recovery in favor of the absence of restrictions. Between 2004-2010, 55 Ream and Run cases have been performed in 52 patients ranging in age from 42-68 years (average 56 years). This series has included 50 males and 2 females. Although formal outcome measures have not been performed on this consecutive series, 5 patients have required additional surgery. Two patients underwent revision glenoid resurfacing for recalcitrant pain with recurrent posterior erosion at 16 and 26 months after the index procedure. One of these patients was female. The other was subsequently determined to have inflammatory osteoarthritis. Two patients underwent repair of a partial subscapularis rupture both of whom were noted to have a smooth, remodeled concavity with rests of fibrocartilage at the time of exploration 3 and 47 months postoperatively. One patient underwent explantation of the humeral prosthesis due to deep infection with Staph. Epidermidis. This patient was subsequently revised to a standard total shoulder arthroplasty after interval placement of an antibiotic cement spacer and parenteral antimicrobial treatment. Two additional patients have complained of persistent pain but have elected not to undergo further surgery. Neither of these patients has demonstrated significant glenoid erosion to suggest that the cause of pain is in fact due to wear at the articulation. Lynch et al have reported on outcomes of the Ream and Run procedure at mid-term followup. In the initial report, 32 of 35 patients demonstrated improved function regaining an average of 4.5 functions on the Simple Shoulder Test (SST).49 Overall average SST score improved from 4.7 to 9.4 at 2-4 years follow-up. Sequential improvement in function was noted all the way up to 36 months after surgery. Patients who had radiographic evidence of a joint space on postoperative x-rays had better outcomes indicating that presumed formation of a fibrocartilage interface correlates with better pain relief and improvement in function. Clinton et al in a similar series demonstrated outcomes comparable to a matched set of patients undergoing total shoulder arthroplasty.50 Again, functional outcomes for those patients undergoing the Ream and Run were noted to improve sequentially out to 3

Recently, Saltzman et al reported on outcomes of the Ream and Run in patients aged 55 years or younger. In terms of pre versus postoperative comparative SST, 53 of 56 patients were improved to a degree comparable to patients who underwent a total shoulder arthroplasty by the same surgeon.51 Patients with mild preoperative glenoid erosion did not demonstrate progression while one patient with moderate erosion progressed to severe erosion. Average medial glenoid erosion measured 1.1 mm at an average of 44 months with the worst case measuring 6.3mm. Nine of 65 shoulders required revision including 4 (6%) conversions to a total shoulder for painful glenoid wear. Patients who underwent revision surgery tended to have a more complicated preoperative course including more severe

Collectively, these results are comparable or superior to previously discussed literature looking at hemiarthroplasty alone or biological resurfacing techniques in this age cohort.23, 25, 29, 33, 52 As our experience with this technique grows, patient selection criteria, indications and techniques have been refined to reflect potential modes of failure and their risk factors. As with all of orthopedics, the right operation for the right problem in the right patient is the key to success. The shoulder arthroplasty surgeon must carefully evaluate each candidate clinically, radiographically and in terms of compliance and expectations. When proper surgical technique is applied to right clinical setting the results of the Ream and Run can be

functional deficits to overcome and a higher incidence of multiple prior surgeries.

osteotomy allows bone to bone healing, this is not guaranteed in all cases. Micromotion at the repair site may stimulate a fibrous union, and release of the subscapularis intraoperatively may disrupt the blood supply to this fragment resulting in avascular necrosis of the lesser tuberosity and inability to heal directly by bony union. While this has not been previously reported in the literature, the author has had occasion to explore 4 cases in which the lesser tuberosity repair ruptured after surgery as detected clinically and radiographically. In all cases, the bone was sclerotic and devoid of any bleeding when drilled at the time of re-repair. Future studies will need to better determine the biology of lesser tuberosity healing but until more is known about how to optimize this process, erring on the side of caution is the safest route to avoid the devastating complication of subscapularis failure. This fact is true regardless of the method of tendon repair used. Because these patients tend to be more active and aggressive in terms of lifestyle pursuits, they need to be educated in terms of recovery expectations so that their ambitions do not compromise their compliance with the recovery protocol.

### **8.3 Stiffness**

Recovery of range of motion is critical to outcomes after the Ream and Run procedure. Residual stiffness will result in obligate, capsular-mediated translations that equate to the same pathomechanics resulting in posterior humeral subluxation and glenoid erosion. The author believes that in all cases, aggressive circumferential capsular releases are necessary to restore motion and selective releases for fear of instability are never indicated. Capsularmediated stability only occurs at the terminal range of motion, which is never a concern in the first 3 months after surgery when the capsule is reforming around the prosthetic joint. Stability in the mid-range is a function of a properly oriented glenoid concavity of sufficient area and a functional rotator cuff. Surgeons should not rely on intraoperative tests of joint stability that measure capsular tension as they are largely irrelevant assuming a properly performed reconstruction.

Given the prior discussion about subscapularis failure, range of motion exercises must be a graduated process that focuses more on frequency than exertion for the first several weeks. Patients must take an active but responsible and educated role in their own recovery and they must understand the potential consequences of noncompliance. This is a delicate balance that requires pre and postoperative education from both the surgeon and therapist. The author has also found it invaluable to identify one or two therapists who take an interest in shoulder arthroplasty and have a better understanding of how to achieve desired results. As with any discipline, frequency, volume and practice beget experience and results in this regard.
