Current Technique for the Ream-and-Run Arthroplasty for Glenohumeral Osteoarthritis

Abstract

Introduction: The ream and run is a technically demanding shoulder arthroplasty for the management of glenohumeral arthritis that avoids the risk of failure of the glenoid component that is associated with total shoulder arthroplasty.

Step 1 surgical approach: After administration of prophylactic antibiotics and a thorough skin preparation, expose the glenohumeral joint through a long deltopectoral incision, incising the subscapularis tendon from its osseous insertion and the capsule from the anterior-inferior aspect of the humeral neck while carefully protecting all muscle groups and neurovascular structures.

Step 2 humeral preparation: Gently expose the proximal part of the humerus, resect the humeral head at 45° to the orthopaedic axis while protecting the rotator cuff, and excise all humeral osteophytes.

Step 3 glenoid preparation: After performing an extralabral capsular release, remove any residual cartilage, drill the glenoid centerline, and ream the glenoid to a single concavity.

Step 4 humeral prosthesis selection: Select a humeral prosthesis that fits the medullary canal and that provides the desired mobility and stability of the prosthesis.

Step 5 humeral prosthesis fixation: Fix the humeral component using impaction autografting.

Step 6 soft-tissue balancing: After the definitive humeral prosthesis is in place, ensure the desired balance of mobility and stability. If there is excessive posterior translation, consider a rotator interval plication.

Step 7 rehabilitation: Achieve and maintain at least 150° of flexion and good external rotation strength.

Results: In our study, comfort and function increased progressively after the ream-and-run procedure, reaching a steady state by approximately twenty months.

What to watch for: IndicationsContraindicationsPitfalls & Challenges.

Fig. 1

Contact pressure. Eccentric loading leads to progressive posterior wear, a glenoid biconcavity, and posterior instability. (Reproduced, with permission of Elsevier, from: Matsen FA 3rd, Clinton J, Rockwood CA Jr, Wirth MA Lippitt MA. Glenohumeral arthritis and its management. In: Rockwood CA Jr; Matsen FA 3rd; Wirth MA; Lippitt SB, editors. The shoulder. 4th ed. Philadelphia: Saunders; 2009.)

Fig. 2

Without glenoid resurfacing. If either a “resurfacing” or a stemmed humeral hemiarthroplasty is performed without resolution of the glenoid biconcavity, the instability and load concentration on the back of the glenoid persists.

Fig. 3

In the ream-and-run procedure, the irregular arthritic glenoid surface (A) is reamed to a single concavity (B), which is subsequently covered with fibrocartilage (C) so that the glenohumeral contact area is optimized. (Reproduced, with permission of Elsevier, from: Matsen FA 3rd, Clinton J, Rockwood CA Jr, Wirth MA Lippitt MA. Glenohumeral arthritis and its management. In: Rockwood CA Jr; Matsen FA 3rd; Wirth MA; Lippitt SB, editors. The shoulder. 4th ed. Philadelphia: Saunders; 2009.)

Fig. 4

Patient position. The patient is positioned in a comfortable beach-chair position with the arm free to move. (Reproduced, with permission of Elsevier, from: Matsen FA 3rd, Clinton J, Rockwood CA Jr, Wirth MA Lippitt MA. Glenohumeral arthritis and its management. In: Rockwood CA Jr; Matsen FA 3rd; Wirth MA; Lippitt SB, editors. The shoulder. 4th ed. Philadelphia: Saunders; 2009.)

Fig. 5

Humeral reaming. A small medullary reamer is introduced medial to the cuff insertion (left). Progressively larger reamers are used until the distal endosteal cortex is engaged (“love at first bite”). Notching of the endosteal cortex is avoided (right).

Fig. 6-A

Glenoid exposure. Exposure is achieved with a sharp retractor on the glenoid neck and with the shaft of the reamer pushing the proximal part of the humerus posteriorly. (Reproduced, with permission of Elsevier, from: Matsen FA 3rd, Clinton J, Rockwood CA Jr, Wirth MA Lippitt MA. Glenohumeral arthritis and its management. In: Rockwood CA Jr; Matsen FA 3rd; Wirth MA; Lippitt SB, editors. The shoulder. 4th ed. Philadelphia: Saunders; 2009.)

Fig. 6-B

Five o’clock capsular release. In the presence of a biconcave glenoid, the extralabral capsular release is continued only to the 5-o’clock position to preserve the inferior glenohumeral sling. (Reproduced, with permission of Elsevier, from: Matsen FA 3rd, Clinton J, Rockwood CA Jr, Wirth MA Lippitt MA. Glenohumeral arthritis and its management. In: Rockwood CA Jr; Matsen FA 3rd; Wirth MA; Lippitt SB, editors. The shoulder. 4th ed. Philadelphia: Saunders; 2009.)

Fig. 6-C

The 360° capsular release. When the shoulder is tight, but there is no biconcavity, the release can be extended all of the way around the glenoid. (Reproduced, with permission of Elsevier, from: Matsen FA 3rd, Clinton J, Rockwood CA Jr, Wirth MA Lippitt MA. Glenohumeral arthritis and its management. In: Rockwood CA Jr; Matsen FA 3rd; Wirth MA; Lippitt SB, editors. The shoulder. 4th ed. Philadelphia: Saunders; 2009.)

Fig. 6-D

Curettage of the glenoid. The residual articular cartilage is curetted from the glenoid face. (Reproduced, with permission of Elsevier, from: Matsen FA 3rd, Clinton J, Rockwood CA Jr, Wirth MA Lippitt MA. Glenohumeral arthritis and its management. In: Rockwood CA Jr; Matsen FA 3rd; Wirth MA; Lippitt SB, editors. The shoulder. 4th ed. Philadelphia: Saunders; 2009.)

Fig. 6-E

Preparation of the glenoid. The ridge between the biconcavities is burred. (Reproduced, with permission of Elsevier, from: Matsen FA 3rd, Clinton J, Rockwood CA Jr, Wirth MA Lippitt MA. Glenohumeral arthritis and its management. In: Rockwood CA Jr; Matsen FA 3rd; Wirth MA; Lippitt SB, editors. The shoulder. 4th ed. Philadelphia: Saunders; 2009.)

Fig. 6-F

Marking the center of the glenoid center with cautery. The point midway between the anterior and posterior aspects of the glenoid and slightly above the superior/inferior midpoint is marked with cautery. (Reproduced, with permission of Elsevier, from: Matsen FA 3rd, Clinton J, Rockwood CA Jr, Wirth MA Lippitt MA. Glenohumeral arthritis and its management. In: Rockwood CA Jr; Matsen FA 3rd; Wirth MA; Lippitt SB, editors. The shoulder. 4th ed. Philadelphia: Saunders; 2009.)

Fig. 6-G

Burring of the glenoid center. The marked point is burred to serve as the starting point for the drill. (Reproduced, with permission of Elsevier, from: Matsen FA 3rd, Clinton J, Rockwood CA Jr, Wirth MA Lippitt MA. Glenohumeral arthritis and its management. In: Rockwood CA Jr; Matsen FA 3rd; Wirth MA; Lippitt SB, editors. The shoulder. 4th ed. Philadelphia: Saunders; 2009.)

Fig. 6-H

Reaming of a concentric glenoid. The glenoid is reamed conservatively to form a single concavity. (Reproduced, with permission of Elsevier, from: Matsen FA 3rd, Clinton J, Rockwood CA Jr, Wirth MA Lippitt MA. Glenohumeral arthritis and its management. In: Rockwood CA Jr; Matsen FA 3rd; Wirth MA; Lippitt SB, editors. The shoulder. 4th ed. Philadelphia: Saunders; 2009.)

Fig. 6-I

Mismatch. The reamed glenoid concavity diameter of curvature is 2 mm greater than that of the humeral head prosthesis, usually 58 and 56 mm, respectively. (Reproduced, with permission of Elsevier, from: Matsen FA 3rd, Clinton J, Rockwood CA Jr, Wirth MA Lippitt MA. Glenohumeral arthritis and its management. In: Rockwood CA Jr; Matsen FA 3rd; Wirth MA; Lippitt SB, editors. The shoulder. 4th ed. Philadelphia: Saunders; 2009.)

Fig. 6-J

Glenoid reaming. Reaming is used to create a single glenoid concavity. Rather than striving to “normalize” the glenoid version (A), we prefer to preserve glenoid bone stock, even if it means accepting some glenoid retroversion (B). (Reproduced, with modification, from: Matsen FA III, Lippitt SB. Shoulder surgery: principles and procedures. 1st ed. Philadelphia: Saunders; 2004. Principles of glenoid arthroplasty. Reproduced with permission of Elsevier.)

Fig. 7-A

The 40/50/60 rule. The reconstruction should allow 40° of external rotation with the subscapularis approximated, 50% posterior translation of the head on the glenoid, and 60° of internal rotation of the arm abducted to 90°. (Reproduced, with permission of Elsevier, from: Matsen FA 3rd, Clinton J, Rockwood CA Jr, Wirth MA Lippitt MA. Glenohumeral arthritis and its management. In: Rockwood CA Jr; Matsen FA 3rd; Wirth MA; Lippitt SB, editors. The shoulder. 4th ed. Philadelphia: Saunders; 2009.)

Fig. 7-B

Forward elevation to 150°. The reconstruction should allow 150° of forward elevation.

Fig. 7-C

Inferior medial abutment. The inferior aspect of the articulation is carefully checked for unwanted contact between the medial aspect of the humerus and the glenoid. (Reproduced, with modification, from: Clinton J, Warme WJ, Lynch JR, Lippitt SB, Matsen FA. Shoulder hemiarthroplasty with nonprosthetic glenoid arthroplasty: the ream and run. Tech Shoulder & Elbow Surg. 2009 Mar;10[1]:43-52. Reproduced with permission of Wolters Kluwer Health.)

Fig. 7-D

Posterior abutment. Unwanted posterior contact between humeral osteophytes and the back of the glenoid can cause the joint to hinge open, rotating about the site of posterior contact on external rotation. (Reproduced, with permission of Elsevier, from: Matsen FA 3rd, Clinton J, Rockwood CA Jr, Wirth MA Lippitt MA. Glenohumeral arthritis and its management. In: Rockwood CA Jr; Matsen FA 3rd; Wirth MA; Lippitt SB, editors. The shoulder. 4th ed. Philadelphia: Saunders; 2009.)

Fig. 7-E

Posterior drop back. If the humeral head drops back out of the glenoid with forward elevation, an eccentric head prosthesis, a thicker head, a rotator interval plication, or a combination of these may be required for stability. (Reproduced, with modification, from: Clinton J, Warme WJ, Lynch JR, Lippitt SB, Matsen FA. Shoulder hemiarthroplasty with nonprosthetic glenoid arthroplasty: the ream and run. Tech Shoulder & Elbow Surg. 2009 Mar;10[1]:43-52. Reproduced with permission of Wolters Kluwer Health.)

Fig. 7-F

Eccentrically anterior head. If a trial with a concentric head reveals posterior instability (A), stability can often be restored by using an eccentrically anterior humeral head component that allows the tuberosities to sit posteriorly while the head remains reduced in the glenoid (B).

Fig. 7-G

Rotator interval closure. If the humeral head drops back when the arm is elevated, consider plicating the rotator interval by suturing the upper subscapularis to the anterior supraspinatus. (Left: Reproduced, with permission of Elsevier, from: Matsen FA 3rd, Clinton J, Rockwood CA Jr, Wirth MA Lippitt MA. Glenohumeral arthritis and its management. In: Rockwood CA Jr; Matsen FA 3rd; Wirth MA; Lippitt SB, editors. The shoulder. 4th ed. Philadelphia: Saunders; 2009. Right: Reproduced, with permission of Wolters Kluwer Health, from: Clinton J, Warme WJ, Lynch JR, Lippitt SB, Matsen FA. Shoulder hemiarthroplasty with nonprosthetic glenoid arthroplasty: the ream and run. Tech Shoulder & Elbow Surg. 2009 Mar;10[1]:43-52.)

Fig. 7-H

Proper register. The humeral head remains centered in the glenoid socket when the arm is at the side (A) and when it is abducted 45° (B). (Reproduced, with modification, from: Matsen FA 3rd, Lippitt SB. Shoulder surgery: principles and procedures. Philadelphia: Saunders; 2004. Reproduced with permission of Elsevier.)

Fig. 8-A

Impaction bone graft. A tight prosthetic fit is achieved by using autogenous bone graft impacted in the medullary canal. (Reproduced, with permission of Elsevier, from: Matsen FA 3rd, Clinton J, Rockwood CA Jr, Wirth MA Lippitt MA. Glenohumeral arthritis and its management. In: Rockwood CA Jr; Matsen FA 3rd; Wirth MA; Lippitt SB, editors. The shoulder. 4th ed. Philadelphia: Saunders; 2009.)

Fig. 8-B

Subscapularis repair. The subscapularis is securely repaired by using six transosseous sutures through the anterior humeral neck cut. (Reproduced, with permission of Elsevier, from: Matsen FA 3rd, Clinton J, Rockwood CA Jr, Wirth MA Lippitt MA. Glenohumeral arthritis and its management. In: Rockwood CA Jr; Matsen FA 3rd; Wirth MA; Lippitt SB, editors. The shoulder. 4th ed. Philadelphia: Saunders; 2009.)

Fig. 9

Increasing head width. If the reconstruction is too loose, the width of the humeral prosthesis is increased.