**6. Surgical technique**

The patient is positioned in a low beach chair position with the head supported in a cerebellar headrest. The body is shifted toward the operative side so the arm can be extended over the edge of the bed for humeral exposure. A rolled towel is placed beneath the medial scapular border to help orient the glenoid toward the operative field. Unless contraindicated, sterile preparation of the field should employ Choraprep solution, which has demonstrated superior bacteriocidal efficacy relative to other preparations. In addition, circumferential biodrape should be used to occlude the axillary region and cover all exposed skin. Receipt of prophylactic antibiotics must be ensured along with availability of necessary instruments and implants and confirmation of the correct patient, procedure and side.

A standard deltopectoral incision is used though some surgeons prefer a more vertical Bankart type incision in Langer's lines. The cephalic vein is taken laterally with the deltoid and the interval is developed from the clavicle to the pectoralis tendon. We do not routinely take down the pectoralis tendon unless necessary for exposure. The deltoid should be reflected off the coracoacromial ligament to facilitate exposure. The clavipectoral fascia should be excised en bloc from the inferior edge of the CA ligament superiorly to the superior edge of the pectoralis major tendon inferiorly and from the lateral border the conjoint tendon medially to the medial border of the anterior deltoid laterally. This opens the humeroscapular motion interface. A curved deltoid retractor such as a Browne's or delta Fukuda is placed behind the humeral head and a right-angle retractor such as Army Navy beneath the conjoint tendon.

The bicipital groove is opened and the biceps is sutured to the traversing pectoralis major tendon to maintain proper length and tension. It is then tenotomized in the rotator interval. The superior and inferior borders of the subscapularis are then dissected out, cauterizing or ligating the circumflex vessels. The author prefers a lesser tuberosity osteotomy for management of the subscapularis. This is done with a broad curved osteotome and started at the deepest portion of the bicipital groove. The tendon-bone fragment is tagged with suture. A curved blunt Hohman retractor is then placed along the anterior inferior humeral head and this is used to tension the humeral insertion of the inferior glenohumeral capsuleligamentous complex. This is then released subperiosteally with progressive external rotation, and this release can be follow around to the humeral bare area posteriorly. This release greatly facilitates surgical dislocation of the humeral head.

Prior to dislocation of the humeral head, a lamina spreader type instrument can be used to distract the glenohumeral joint. This tensions the posterior capsule allowing superior visibility for thorough capsulotomy along the length of the posterior glenoid. A thorough release of the posterior capsule facilitates posterior humeral subluxation during glenoid exposure. Although some surgeons advocate selective capsular releases depending on the degree of preoperative humeral posterior subluxation, the author does not feel that capsular tissues play a role in glenohumeral stability except during the extremes of range of motion provided an adequate concavity is restored along the axis of the scapula and proper

Westchester, PA), which includes press-fit and cemented stem options and a dual eccentricity design that allows precise placement of the humeral head on the humeral osteotomy surface. This precision improves the accuracy of restoring the humeral center of rotation and head-tuberosity relationship, which is critical in defining soft-tissue balance

The patient is positioned in a low beach chair position with the head supported in a cerebellar headrest. The body is shifted toward the operative side so the arm can be extended over the edge of the bed for humeral exposure. A rolled towel is placed beneath the medial scapular border to help orient the glenoid toward the operative field. Unless contraindicated, sterile preparation of the field should employ Choraprep solution, which has demonstrated superior bacteriocidal efficacy relative to other preparations. In addition, circumferential biodrape should be used to occlude the axillary region and cover all exposed skin. Receipt of prophylactic antibiotics must be ensured along with availability of necessary instruments and implants and confirmation of the correct patient, procedure and side. A standard deltopectoral incision is used though some surgeons prefer a more vertical Bankart type incision in Langer's lines. The cephalic vein is taken laterally with the deltoid and the interval is developed from the clavicle to the pectoralis tendon. We do not routinely take down the pectoralis tendon unless necessary for exposure. The deltoid should be reflected off the coracoacromial ligament to facilitate exposure. The clavipectoral fascia should be excised en bloc from the inferior edge of the CA ligament superiorly to the superior edge of the pectoralis major tendon inferiorly and from the lateral border the conjoint tendon medially to the medial border of the anterior deltoid laterally. This opens the humeroscapular motion interface. A curved deltoid retractor such as a Browne's or delta Fukuda is placed behind the humeral head and a right-angle retractor such as Army Navy

The bicipital groove is opened and the biceps is sutured to the traversing pectoralis major tendon to maintain proper length and tension. It is then tenotomized in the rotator interval. The superior and inferior borders of the subscapularis are then dissected out, cauterizing or ligating the circumflex vessels. The author prefers a lesser tuberosity osteotomy for management of the subscapularis. This is done with a broad curved osteotome and started at the deepest portion of the bicipital groove. The tendon-bone fragment is tagged with suture. A curved blunt Hohman retractor is then placed along the anterior inferior humeral head and this is used to tension the humeral insertion of the inferior glenohumeral capsuleligamentous complex. This is then released subperiosteally with progressive external rotation, and this release can be follow around to the humeral bare area posteriorly. This

Prior to dislocation of the humeral head, a lamina spreader type instrument can be used to distract the glenohumeral joint. This tensions the posterior capsule allowing superior visibility for thorough capsulotomy along the length of the posterior glenoid. A thorough release of the posterior capsule facilitates posterior humeral subluxation during glenoid exposure. Although some surgeons advocate selective capsular releases depending on the degree of preoperative humeral posterior subluxation, the author does not feel that capsular tissues play a role in glenohumeral stability except during the extremes of range of motion provided an adequate concavity is restored along the axis of the scapula and proper

release greatly facilitates surgical dislocation of the humeral head.

and proper rotator cuff function.

**6. Surgical technique** 

beneath the conjoint tendon.

humeral retrotorsion is selected. In the author's personal series, circumferential capsular releases have never resulted in postoperative posterior instability but do improve range of motion during the early recovery. If there is a concern about posterior laxity, the rotator interval can be closed slightly more medially to provide a checkrein against posterior translation at the conclusion of the case.

The humeral osteotomy is then made along the anatomical neck generally in 25-30 degrees of retrotorsion. It is critical that this cut is flush with the articular-sided insertion of the supraspinatus tendon fibers so the anatomical reconstruction of the head-tuberosity relationship can be properly achieved.(Figure 8) Once the cut is made and refined, osteophytes around the margins of the anatomical neck can be removed, particularly those inferiorly which can cause calcar impingement with the inferior glenoid if not cleared out. A head diameter that best covers the osteotomy surface is then chosen. It is best to err toward the smaller size assuming there will be no uncovered bone that would impinge during glenohumeral rotation.

Fig. 8. The humeral osteotomy should be flush with the insertion of the supraspinatus tendon to restore the head-tuberosity relationship. The trial stem should be positioned to restore humeral retrotorsion of approximately 25-30 degrees.

If a stemmed arthroplasty is to be used, the humeral canal can then be prepped via the conventions of the given system and a trial stem placed. If a cap prosthesis is chosen, then the head can be reamed and the cap sized according to the system's technique.

The humerus is then subluxated posteriorly using a Fukuda or similar retractor. A complete circumferential release of the subscapularis can now safely be performed. The interval between the anterior capsule and inferior muscular fibers of the subscapularis is developed with Metzenbaum scissors allowing safe release of the anterior capsular from the glenoid rim and release of adhesions to the coracoid base. All adhesions should be released so that external rotation can be restored. The surgeon should feel a soft bounce when the subscapularis is pulled laterally. A blunt Hohman or spiked ribbon retractor can then be placed medially within the subscapularis fossa with the tendon and lesser tuberosity tucked medially behind it. This should allow full visualization down the anterior face of the scapular body, which is critical for restoring orientation of the glenoid concavity.

Humeral Hemiarthroplasty with Spherical Glenoid

humeral prosthesis.

achieved.

Reaming: Theory and Technique of The Ream and Run Procedure 593

should exit the anterior glenoid neck between the upper and lower crurae of the subscapularis fossa. The author uses the convention of being able to palpate the pin tip when the PIP joint of the index finger is placed against the anterior glenoid rim. If it exists too anteriorly then

Once the pin is properly positioned, the cannulated reamer can be introduced. The blades should be spinning prior to contact with the bone and the glenoid should be progressively reamed until circumferential contact occurs and a full concavity is achieved. (Figure 10) The goals of reaming are: 1) to restore glenoid version; and 2) to restore a smooth concavity. Once these goals are achieved, the surgeon must inspect the glenoid surface, the bone quality, the surface area and the degree of medialization that occurs from correction. If corrective reaming results in significant medialization, exposure of cancellous bone within the glenoid vault or loss of surface area as the glenoid narrows, placement of a glenoid prosthesis may be necessary. Ideally, there should be firm subchondral bone to support the

Next a small drill is used to make multiple perforations in the reamed glenoid face. This serves two purposes.(Figure 11) Firstly, it decompresses the venous congestion than can occur in arthritic bone, which may improve pain relief. Secondly, it permits egress of bone marrow stem cells to help reform a fibro-cartilaginous coating on the reamed glenoid face. The final humeral prosthesis is then inserted according to the specifications of the system. It is critical that the humeral head be optimally positioned to restore the center of rotation of

Fig. 10. The chosen reamer is introduced and the glenoid reamed until a smooth concavity is

reaming will result in persistent retroversion that can lead to posterior instability.

the joint and to restore the proper head-tuberosity relationship.(Figure 12)

The inferior capsule is then release sharply in an extra labral fashion keeping the knife parallel to and against bone. Care should be taken to completely release the insertion of the anterior inferior and posterior inferior glenohumeral ligament from its glenoid-sided insertion. The author believes that selective capsular releases are never indicated assuming that the glenoid version is properly corrected and an adequate concavity is restored. The Fukuda retractor ring can be twisted off of the inferior glenoid rim to facilitate release of the posterior inferior capsule. Once a sufficient release has been performed, adequate glenoid exposure should permit insertion of the glenoid reamers. Internal rotation (rather than the conventional external rotation) can sometimes facilitate posterior humeral subluxation. Release of the coracohumeral ligament is sometimes necessary to improve glenoid exposure by further allowing the humerus to translate posteriorly.

The center of the existing glenoid concavity is then determined. The author uses a curved backed drill guide to help find the centering or slippage point. If there is a double concavity present, or if there is significant posterior glenoid erosion, the centering point often needs to be shifted somewhat anteriorly to properly restore glenoid version by reaming the high side. Any central ridges can be burred in advance to provisionally restore a concavity. In cases of significant posterior glenoid wear or double concavity, a flatter reamer can be used for provisional reshaping prior to definitive reestablishment of the concavity.

Once the centering point has been determined, a threaded-tipped Steinmann pin is drilled parallel to the glenoid centerline.(Figure 9) Because the scapular is a curved structure, this pin

Fig. 9. The glenoid labrum is preserved during glenoid exposure and capsular releases. The centering point for the is determined and a threaded-tipped Steinmann pin is drilled to reorient the glenoid so that it is retroverted roughly 10 degrees relative to the axis of the scapular body.

The inferior capsule is then release sharply in an extra labral fashion keeping the knife parallel to and against bone. Care should be taken to completely release the insertion of the anterior inferior and posterior inferior glenohumeral ligament from its glenoid-sided insertion. The author believes that selective capsular releases are never indicated assuming that the glenoid version is properly corrected and an adequate concavity is restored. The Fukuda retractor ring can be twisted off of the inferior glenoid rim to facilitate release of the posterior inferior capsule. Once a sufficient release has been performed, adequate glenoid exposure should permit insertion of the glenoid reamers. Internal rotation (rather than the conventional external rotation) can sometimes facilitate posterior humeral subluxation. Release of the coracohumeral ligament is sometimes necessary to improve glenoid exposure

The center of the existing glenoid concavity is then determined. The author uses a curved backed drill guide to help find the centering or slippage point. If there is a double concavity present, or if there is significant posterior glenoid erosion, the centering point often needs to be shifted somewhat anteriorly to properly restore glenoid version by reaming the high side. Any central ridges can be burred in advance to provisionally restore a concavity. In cases of significant posterior glenoid wear or double concavity, a flatter reamer can be used for

Once the centering point has been determined, a threaded-tipped Steinmann pin is drilled parallel to the glenoid centerline.(Figure 9) Because the scapular is a curved structure, this pin

Fig. 9. The glenoid labrum is preserved during glenoid exposure and capsular releases. The centering point for the is determined and a threaded-tipped Steinmann pin is drilled to reorient the glenoid so that it is retroverted roughly 10 degrees relative to the axis of the

scapular body.

by further allowing the humerus to translate posteriorly.

provisional reshaping prior to definitive reestablishment of the concavity.

should exit the anterior glenoid neck between the upper and lower crurae of the subscapularis fossa. The author uses the convention of being able to palpate the pin tip when the PIP joint of the index finger is placed against the anterior glenoid rim. If it exists too anteriorly then reaming will result in persistent retroversion that can lead to posterior instability.

Once the pin is properly positioned, the cannulated reamer can be introduced. The blades should be spinning prior to contact with the bone and the glenoid should be progressively reamed until circumferential contact occurs and a full concavity is achieved. (Figure 10) The goals of reaming are: 1) to restore glenoid version; and 2) to restore a smooth concavity. Once these goals are achieved, the surgeon must inspect the glenoid surface, the bone quality, the surface area and the degree of medialization that occurs from correction. If corrective reaming results in significant medialization, exposure of cancellous bone within the glenoid vault or loss of surface area as the glenoid narrows, placement of a glenoid prosthesis may be necessary. Ideally, there should be firm subchondral bone to support the humeral prosthesis.

Next a small drill is used to make multiple perforations in the reamed glenoid face. This serves two purposes.(Figure 11) Firstly, it decompresses the venous congestion than can occur in arthritic bone, which may improve pain relief. Secondly, it permits egress of bone marrow stem cells to help reform a fibro-cartilaginous coating on the reamed glenoid face.

The final humeral prosthesis is then inserted according to the specifications of the system. It is critical that the humeral head be optimally positioned to restore the center of rotation of the joint and to restore the proper head-tuberosity relationship.(Figure 12)

Fig. 10. The chosen reamer is introduced and the glenoid reamed until a smooth concavity is achieved.

Humeral Hemiarthroplasty with Spherical Glenoid

Reaming: Theory and Technique of The Ream and Run Procedure 595

Excess anterior and posterior overhang must be avoided and there should be smooth transition at the calcar that prevents boney impingement in this region. A head thickness that corresponds to normal anatomy should be chosen. If the system used provides 3 offset options for each diameter, it is best to choose the middle size to prevent over or under stuffing of the joint. Conventional on-table measurements of passive translation are not helpful in determining proper soft tissue tension as they do no correlate with dynamic stability in the mid range of motion after surgery. It is best to err toward the looser side with the Ream and Run as it facilitates recovery of motion which is critical to outcomes and it does not correlate

A secure subscapularis repair is essential to permit early range of motion. The author currently uses the technique described by Millett et al using cerclage sutures looped around the humeral stem.47 If a porous ingrowth stem is used, the author uses two 1mm cables instead because micromotion of the sutures against the stem coating will result in suture rupture.(Figure 13) These cables are supplemented by a suture tension band construct tied over a cortical button lateral to the bicipital groove. If cables are used, the crimps are positioned in the bicipital groove and covered over by the biceps tendon to prevent softtissue irritation. The lateral part of the rotator interval is then closed. If there is concern about posterior instability, additional interval sutures can be placed more medially though this may compromise external rotation and potentially decentralize the humeral head.

Fig. 13. A secure repair of the subscapularis is essential regardless of the technique. In this picture, horizontal cerclage cables have been used to compress the lesser tuberosity

Immediate range of motion exercises are begun under the supervision of the therapist. Forward elevation to 140 degree and external rotation to 40 degree is allowed along with

fragment to its osteotomy bed.

**7. Post-operative protocol** 

with postoperative instability assuming the glenoid has been properly corrected.

Fig. 11. Multiple holes are drilled into the reamed glenoid to decompress venous congestion and promote egress of stem cells to promote fibrocartilage formation.

Fig. 12. The humeral head must achieve anatomical reconstruction with regard to coverage of the osteotomy and restoration of the head-shaft and head-tuberosity relationship. The head should have an anatomical height that does not overstuff the joint.

Fig. 11. Multiple holes are drilled into the reamed glenoid to decompress venous congestion

Fig. 12. The humeral head must achieve anatomical reconstruction with regard to coverage of the osteotomy and restoration of the head-shaft and head-tuberosity relationship. The

head should have an anatomical height that does not overstuff the joint.

and promote egress of stem cells to promote fibrocartilage formation.

Excess anterior and posterior overhang must be avoided and there should be smooth transition at the calcar that prevents boney impingement in this region. A head thickness that corresponds to normal anatomy should be chosen. If the system used provides 3 offset options for each diameter, it is best to choose the middle size to prevent over or under stuffing of the joint. Conventional on-table measurements of passive translation are not helpful in determining proper soft tissue tension as they do no correlate with dynamic stability in the mid range of motion after surgery. It is best to err toward the looser side with the Ream and Run as it facilitates recovery of motion which is critical to outcomes and it does not correlate with postoperative instability assuming the glenoid has been properly corrected.

A secure subscapularis repair is essential to permit early range of motion. The author currently uses the technique described by Millett et al using cerclage sutures looped around the humeral stem.47 If a porous ingrowth stem is used, the author uses two 1mm cables instead because micromotion of the sutures against the stem coating will result in suture rupture.(Figure 13) These cables are supplemented by a suture tension band construct tied over a cortical button lateral to the bicipital groove. If cables are used, the crimps are positioned in the bicipital groove and covered over by the biceps tendon to prevent softtissue irritation. The lateral part of the rotator interval is then closed. If there is concern about posterior instability, additional interval sutures can be placed more medially though this may compromise external rotation and potentially decentralize the humeral head.

Fig. 13. A secure repair of the subscapularis is essential regardless of the technique. In this picture, horizontal cerclage cables have been used to compress the lesser tuberosity fragment to its osteotomy bed.
