**9. Results**

When patient selection is combined with surgical technique that achieves the principles of Ream and Run, outcomes can be comparable to total shoulder arthroplasty in terms of pain relief, range of motion and function. Given that no specific restrictions are placed on patients postoperatively, results in terms of return to physically demanding leisure time physical activities can be outstanding. Patients have returned to sports such as water skiing, weight lifting, competitive tennis, and other outdoor pursuits. As many of these patients previously engaged in activities that may have contributed to early glenohumeral degenerative disease, the ability to return to similar activities, albeit in a modified setting, is a significant improvement in their health-related quality of life.

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

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

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

When patient selection is combined with surgical technique that achieves the principles of Ream and Run, outcomes can be comparable to total shoulder arthroplasty in terms of pain relief, range of motion and function. Given that no specific restrictions are placed on patients postoperatively, results in terms of return to physically demanding leisure time physical activities can be outstanding. Patients have returned to sports such as water skiing, weight lifting, competitive tennis, and other outdoor pursuits. As many of these patients previously engaged in activities that may have contributed to early glenohumeral degenerative disease, the ability to return to similar activities, albeit in a modified setting, is

discipline, frequency, volume and practice beget experience and results in this regard.

a significant improvement in their health-related quality of life.

compromise their compliance with the recovery protocol.

**8.3 Stiffness** 

**9. Results** 

performed reconstruction.

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 years postoperatively.

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

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

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**28** 

*Germany* 

 **Development of Proprioception** 

*1Department of Orthopedics, Trauma Surgery and Paraplegiology,* 

Since the introduction of shoulder arthroplasty in 1893 by the French surgeon Jule-Émile Péan [18], the indications for shoulder replacement have expanded. Today shoulder arthroplasty is a common treatment for glenohumeral osteoarthritis [2]. Shoulder arthroplasty can significantly improve the function of osteoarthritic shoulders [7, 13, 19, 27]. Comparing the results, TSR offers better short- and mid-term results, but has the risk of long-term problems as the glenoid loosening [2]. In our practice patients with glenohumeral osteoarthritis will receive a total shoulder arthroplasty. As an exception patients with osteoarthritis which is limited to the humeral head without eccentric erosion of a stable sclerotic glenoid (Typ A1 glenoid according to Walch [28]) can be treated with hemiarthroplasty (HA). If the glenoid shows eccentric posterior wear (> A1), a TSR is

The use of total shoulder replacement in the setting of rotator cuff-tear arthropathy (CTA) has led to poor outcomes because of early glenoid implant failure [17]. These failures were the result of early glenoid loosening caused by altered biomechanics in the cuff-deficient shoulder. The treatment of choice for most used to be hemiarthroplasty. Although good relief from pain has usually been obtained, most patients with CTA and subsequent hemiarthroplasty had a limited range of movement, leading to difficulties with the activities of daily living. These poor results let to the development of the reverse shoulder prosthesis, as a new method for treating CTA. Using the reverse prosthesis in CTA, favorable outcomes

In order to use the replaced shoulder for ADLs the concerted function of the active

In 1906, Charles Scott Sherrington published his work about proprioception [26]. He defined the term proprioception as the awareness of movement derived from muscular, tendon, and articular sources. Since then physiologists and anatomists are searching for specialized nerve endings that transmit data on joint capsule and muscle tension [11, 30]. It is known that joint proprioception plays a considerable role in stabilization of the normal healthy

stabilizers and the passive restraints of the replaced shoulder joint is necessary.

**1. Introduction** 

recommended.

have been reported [15, 17].

**2. Shoulder proprioception** 

**After Shoulder Arthroplasty** 

*2Carl-Gustav Carus University of Dresden, Dresden* 

Michael W. Maier1 and Philip Kasten2

*University of Heidelberg, Heidelberg* 

