Glenohumeral Arthritis: Hemiarthroplasty With Concentric Glenoid Reaming (Ream and Run)

Andrew Green

INTRODUCTION

Anatomic total shoulder arthroplasty (aTSA) has been considered the gold standard for the surgical treatment of advanced glenohumeral osteoarthritis with consistently excellent outcomes. However, longer-term failure due to glenoid component loosening is well recognized and often leads to functional deterioration and may necessitate complex revision surgery.¹ This is especially relevant to younger and more active patients who have greater functional demands and expectations, as well as a longer life expectancy.²^, ³^, ⁴ ^and ⁵ The expected increase in future demand for shoulder arthroplasty among younger patients, as well as an aging population, will likely increase the prevalence of glenoid component failure.⁶ There has been limited interest in humeral head replacement (HHR) without treatment of the glenoid. The relatively small randomized clinical trials comparing HHR with aTSA report greater improvement for aTSA and the need for early revision in up to 30% of HHR cases.⁷^, ⁸ ^and ⁹ Several techniques of soft tissue glenoid resurfacing arthroplasty were advocated but have fallen out of favor due to unsatisfactory outcomes. Consequently, humeral hemiarthroplasty without glenoid treatment is considered to have limited application.¹⁰ Ream and run (RnR) was developed by Dr Frederick (Rick) Matsen as an alternative to aTSA specifically to treat advanced glenohumeral arthritis while avoiding the issues related to the limitations of standard prosthetic glenoid components.¹¹ Despite very promising results in a select patient population, there has not been widespread acceptance of this procedure. The purpose of this chapter is to provide a detailed description of author’s approach to the evaluation and management of patients with advanced glenohumeral arthritis using RnR shoulder arthroplasty.

INDICATIONS

RnR shoulder arthroplasty is generally indicated for patients with advanced glenohumeral arthritis and an intact rotator cuff who have shoulder pain and dysfunction that has failed nonoperative treatment and affects their quality of life to an extent that they cannot tolerate it. Most patients in reported series had primary glenohumeral osteoarthritis (GHOA). A much smaller percentage had capsulorrhaphy arthropathy after prior anterior instability repair, and even smaller percentages with other diagnoses.¹² RnR is rarely considered for other types of glenohumeral arthritis, with inflammatory arthropathy being a relative contraindication. Compared with aTSA, the decision to proceed with RnR is more nuanced and needs to consider in greater detail the patient’s postoperative functional and activity goals and expectations, as well as tolerance for a more difficult recovery. Published reports from Dr Matsen’s group strongly suggest that that patients with primary glenohumeral
osteoarthritis and capsulorrhaphy have the best results after RnR especially compared with patients with posttraumatic glenohumeral arthritis, multiply operated shoulders, and patients with inflammatory arthritis.¹² Subjective patient factors including resilience and toughness and motivation also appear to be important for successful outcome of RnR. As stated by Dr Matsen, RnR is “not for every patient, every surgeon, or every problem.”¹³

CONTRAINDICATIONS

Common contraindications for shoulder anatomic shoulder arthroplasty including rotator cuff tearing, neurologic conditions affecting the shoulder girdle, active infection, poor patient understanding or compliance, and poorly managed medical comorbidities also apply to RnR. Other relative contraindications include inflammatory arthritis and chronic pain syndromes. Interestingly, RnR is uncommonly performed in female patients.¹²^,¹⁴ This is most likely due to differing goals for postsurgical strenuous activities rather than a purely sex-based decision.

PREOPERATIVE PREPARATION

Patient Evaluation

The primary purpose of the preoperative evaluation is to determine the etiology of a patient’s shoulder pain and dysfunction, quantify the extent and severity of the glenohumeral pathoanatomy, assess their postoperative goals and expectations, and plan for the surgical procedure that is most appropriate for the individual patient. A detailed and thorough history, physical examination, and standard series of plain radiographs is sufficient in the vast majority of cases to establish the diagnosis of glenohumeral arthritis. Advanced imaging is rarely necessary in the initial evaluation.

History

A detailed and complete history is obtained to understand the patient’s current symptoms of shoulder pain and dysfunction. There are specific historical factors that relate to establishing the diagnosis, such as prior surgical procedures, as well as to determine appropriate management.

A detailed understanding of the patient’s symptoms of pain, location and severity, and relieving and aggravating factors is necessary to understand the extent to which shoulder arthritis affects their quality of life. The patient’s current activities and future goals for activities need to be understood and considered to determine the appropriate arthroplasty treatment. The ideal patient for RnR is physically active, either occupationally and/or recreationally, highly motivated to remain so, and determined to pursue and endure the often difficult postoperative recovery.

It is critically important to rule out other conditions that can cause shoulder and upper extremity symptoms. Most notably, cervical spine disorders that can affect root levels that cause shoulder and arm pain. It can be difficult to establish the relative contribution of these symptoms in patients with concomitant glenohumeral arthritis and cervical spine disease.

Information about prior shoulder injuries and surgery is necessary to fully understand the pathoanatomy. Specific prior surgical procedures, especially glenohumeral instability repairs, may directly relate to the pathoanatomy including the status of the subscapularis tendon and glenoid deformity. Overtightening anterior instability repairs cause capsulorrhaphy arthropathy, which is associated with internal rotation contracture and posterior glenoid wear.¹⁵ Previous surgery is also associated with an increased risk of infection after RnR, and the author routinely obtains intraoperative tissue cultures in these cases. Similarly, corticosteroid injection performed within 3 months of shoulder arthroplasty is associated with increased risk of periprosthetic joint infection.¹⁶ Use of biologic and immunosuppressive medications is associated with increased risk of wound healing problems and infection and need to be managed appropriately. Testosterone use is also associated with increased Cutibacterium acnes burden and postoperative infection.¹⁷^,¹⁸

Physical Examination

An orderly approach to the physical examination of a patient with glenohumeral arthritis is essential to determining the relationship between the clinical presentation and the shoulder pathology. This includes observation, palpation, assessment of shoulder range of motion and shoulder girdle strength, and various special maneuvers.

Visual evaluation of the patient with a shoulder disorder requires that the entire shoulder girdle be disrobed so that the anterior, lateral, and posterior aspects can be seen. Skin lesions from acne are important to note as this may be associated with increased risk of periprosthetic joint infection (PJI). Scars from previous surgery should be noted. Muscle development is reflective of the intensity of a patient’s physical activity. Muscle atrophy may be indicative of disuse, nerve injury, or significant rotator cuff disease. Infraspinatus atrophy is suggestive of rotator cuff pathology.

Direct palpation of specific anatomic structures can identify tenderness that can be associated with specific shoulder conditions and rule out other causes of shoulder pain such as acromioclavicular arthritis, biceps tendinopathies, and rotator cuff syndromes that may be present in patients with various degrees of glenohumeral arthritis. The humeral head of patients with advanced GHOA and posterior glenoid wear and posterior humeral subluxation is often prominent and palpable posterior to the acromion. Similarly, the humeral head in patients with severe glenoid erosion may be medialized relative to the acromion.

Patients with advanced glenohumeral arthritis present with various degrees of limitation of shoulder range of motion (Figure 45-1A and B). Active and passive range of motion should be assessed. Differences in active and passive motion could be the result of pain or weakness. Limitation of external rotation is especially important to surgical decision making. Most patients with advanced GHOA have good strength assessed with manual muscle testing. Strength testing in the directions of elevation, external rotation, and internal rotation can provide a rough assessment of the integrity and function of the rotator cuff and deltoid. Unfortunately, specific assessment of rotator cuff strength can be difficult to interpret when glenohumeral motion is severely limited. Substantial weakness especially in internal and external rotation is often the result of extensive rotator cuff pathology.

FIGURE 45-1 Preoperative images of a patient with advanced glenohumeral osteoarthritis of the left shoulder demonstrating limited (A) active forward elevation and (B) active external rotation. The right shoulder is less severely affected.

Lastly, while special physical examination maneuvers and tests may be helpful in the diagnostic evaluation of some shoulder disorders, they have less of a role in the evaluation of patients with advanced glenohumeral osteoarthritis and should not be relied upon.

Plain Radiographs

The initial evaluation of all shoulder conditions includes a series of high-quality plain radiographs. This typically includes a true anteroposterior (AP) (Grashey view), outlet, and axillary lateral radiograph (Figure 45-2A and B). Plain radiographs should be sufficient to establish the specific diagnosis of the glenohumeral arthritis. The true AP demonstrates the glenohumeral joint and the coronal plain glenoid and proximal humerus pathoanatomy. Large humeral osteophytes can be associated with limited shoulder motion. Likewise, humeral flattening can be associated with limited shoulder rotation. Medialization of the humerus relative to the acromion can be the result of concentric and eccentric glenoid wear, in the latter instance with associated posterior humeral subluxation. Degenerative changes, spurring and subcortical cysts, at the greater tuberosity footprint are associated with rotator cuff tearing. The outlet view will demonstrate posterior humeral subluxation. Particular attention to the technique used to obtain the axillary lateral is important. The so-called “truth view” described by Dr Matsen aligns the humeral shaft with the scapular body the facilitates demonstration of posterior humeral subluxation (Figure 45-2B).¹⁹ While the true AP can be used to estimate glenoid inclination, and the axillary lateral can be used to estimate glenoid version, computerized tomography (CT) is more accurate and reproducible (Figure 45-3).

FIGURE 45-2 Preoperative plain radiographs of a patient with advanced glenohumeral osteoarthritis.

A, True anterior posterior image with arrow pointing to a large inferior humeral head spur. B, Axillary lateral image demonstrating a B2 glenoid with posterior glenoid wear and posterior humeral subluxation. Heavy arrow is pointing to the anterior paleoglenoid, and thin arrow is pointing to the posterior neoglenoid.

FIGURE 45-3 Preoperative axial CT scan at the midglenoid level of the shoulder of the same patient in Figure 45-2 demonstrating posterior glenoid wear and posterior humeral subluxation.

Heavy arrow is pointing to the anterior paleoglenoid, and thin arrow is pointing to the posterior neoglenoid.

Advanced Imaging

Advanced imaging is helpful in preoperative planning to more precisely define the pathoanatomy associated with glenohumeral arthritis. GHOA is uncommonly associated with significant
rotator cuff pathology, especially in younger patients. In older patients and cases with degenerative changes suggesting rotator cuff tearing, magnetic resonance imaging (MRI) can be used to evaluate the rotator cuff. Nevertheless, the author rarely uses MRI when evaluating patients for RnR. CT scans are primarily used to evaluate glenoid pathoanatomy. Although the rotator cuff tendons are not well visualized on CT scan, the muscles can be evaluated for fatty infiltration and atrophy. CT scan is used to determine glenoid version, inclination, wear patterns, and bone quantity and quality, all important considerations when determining the type of shoulder arthroplasty (Figure 45-3).

Decision Making and Patient Preparation

RnR should be presented as an alternative to aTSA for appropriate patients. The issues of postoperative activity goals, postoperative recovery, and short- and long-term outcomes of the procedures should be carefully explained with particular reference to the problem of prosthetic glenoid loosening and failure.²⁰ Patient participation in the early phases of postoperative recovery is critically important. Some RnR patients have more pain early after surgery than patients with aTSA, likely due to the fact that their glenoid has not been resurfaced. Patients with low physical demands and older patients may be better served by having an aTSA. Additionally, patients should be informed that RnR is associated with a higher rate, up to 10%, of early failure and need for revision arthroplasty due to persistent pain and limited shoulder motion.¹²^,²¹^,²² In contrast, early need for revision is rare after aTSA except to treat acute post-operative complications. On the other hand, aTSA is prone to later glenoid failure with associated pain and dysfunction that may require revision shoulder arthroplasty that is often complicated by severe glenoid bone loss. With these caveats, a patient undergoing RnR can expect an excellent result that rivals the outcome of aTSA and avoids the issue of glenoid failure.²¹^,²³

Preoperative skin preparation is a topic of considerable interest. The shoulder biome, especially the presence of C. acnes, has led to the investigation of various methods to clean the skin and prevent deeper wound contamination. Benzoyl peroxide appears to be significantly more effective at reducing C. acnes burden at all tissue levels compared with chlorhexidine.²⁴^, ²⁵^, ²⁶ ^and ²⁷

The author provides preoperative teaching regarding the differences between RnR and aTSA, including technical aspects, risks and benefits, and postoperative recovery and rehabilitation. It is important that the patients maintain a healthy lifestyle. Preoperative instruction in the expected postoperative rehabilitation exercises can further help patients to prepare for their recovery.

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