Select antibiotic prophylaxis in consideration of the observation that Propionibacterium acnes and coagulase-negative Staphylococcus are the organisms most commonly found in association with failed shoulder arthroplasties. Our infectious disease service currently recommends a combination of ceftriaxone (one dose of 2 g) and vancomycin (1 g every twelve hours, for two doses) for individuals not allergic to cephalosporins and clindamycin for those allergic to cephalosporins.

With the patient secure in a comfortable beach-chair position and the arm that is to be surgically treated freely movable, carefully prepare and drape the skin excluding exposed skin from the surgical field (Fig. 4).

Prepare 3 L of saline solution containing 3 g of vancomycin and 3 g of ceftriaxone for irrigation. Use this full volume for irrigation throughout the procedure.

Incise the skin along a 10-cm line from the midpart of the clavicle across the coracoid process.

Using a new blade that has not passed through the skin, split the deltopectoral interval and clavipectoral fascia, preserving the coracoacromial ligament.

Incise the subscapularis tendon from its osseous insertion, maximizing tendon length and carefully preserving the long head of the biceps as well as the transverse humeral ligament.

Incise the capsule from the anterior and inferior aspect of the humerus, carefully protecting the nearby neurovascular structures.

Frequently irrigate the wound using antibiotic-containing saline solution throughout the procedure to reduce the risk of contamination.

Insert a broad flat (i.e., Darrach) retractor between the humeral head and the glenoid.

Gently (!) dislocate the proximal part of the humerus with a combination of external rotation, extension, and adduction of the humerus.

Through a starting point on the humeral articular surface near the center of the supraspinatus insertion, begin reaming the medullary canal with cylindrical reamers of progressively larger diameter, stopping with the size of reamer that just begins to engage the endosteal cortex when it is fully inserted (Fig. 5). Avoid notching the endosteal cortex because doing so weakens the bone, predisposing it to fracture.

Using this reamer as an indication of the intramedullary axis of the humerus, resect the humeral head at a 45° angle to this axis, taking care to protect the rotator cuff; the cut surface should face 30° posterior to the transcondylar axis of the elbow (retroversion). We do not attempt to match the patient’s humeral version if it is other than 30°.

While carefully protecting the neurovascular structures, completely resect the osteophytes from around the humeral neck, anteriorly, inferiorly, and posteriorly.

Preserve all resected bone in a sterile covered container with 1 g of vancomycin in a small volume of saline solution for later use as bone graft.

With the upper extremity supported on a padded stand, place a broad retractor behind the glenoid to retract the proximal part of the humerus posteriorly (Fig. 6-A).

Incise the capsule from the labrum, leaving the labrum attached to the glenoid, and retract the capsule with a sharp-tipped retractor placed on the glenoid neck. Release the anterior retractor frequently to relieve pressure on the brachial plexus.

If the preoperative axillary radiograph shows posterior subluxation, stop the capsular release at the inferior aspect of the glenoid (Fig. 6-B). If the shoulder is tight, but not posteriorly subluxated, perform a 360° extralabral periglenoid capsular release (Fig. 6-C).

Curet any residual cartilage from the surface of the glenoid (Fig. 6-D). If this exposes a biconcavity, burr down the ridge between the two concavities (Fig. 6-E).

Locate the position of the hole for the nub of the glenoid reamer: midway between the front and the back of the glenoid and slightly above the superior/inferior midpoint (Figs. 6-F and 6-G).

After drilling this hole, ream the glenoid to achieve a single smooth glenoid concavity using a reamer with a diameter of curvature 2 mm greater than that of the humeral head prosthesis (Fig. 6-H). We almost always use a 58-mm-diameter reamer in conjunction with a 56-mm-diameter humeral head (Fig. 6-I). This large diameter of curvature optimizes the surface area for load transfer and the stability of the reconstruction.

When reaming, prioritize bone preservation (i.e., minimize bone removal) over “normalization” of the glenoid version (Fig. 6-J). We have found that attempting to ream the anterior side to “correct” for glenoid retroversion requires substantial bone removal and does not enhance stability.

Using instruments with a stem diameter equal to that of the largest medullary reamer that was fully inserted into the medullary canal, broach the proximal part of the humerus. With some systems, the broach is the same as the trial humeral component.

Select trial humeral heads of a diameter of curvature 2 mm smaller than that to which the glenoid was reamed (56 mm [for the humeral head] in almost all cases).

Select the trial humeral head with a height that allows 60° of internal rotation of the arm abducted to 90° and just less than 50% posterior subluxation of the humeral head on the glenoid and 40° of external rotation with the subscapularis approximated (Fig. 7-A) and 150° of forward elevation (Fig. 7-B).

Check to be sure that there is no unwanted contact between bone at the medial (Fig. 7-C) or posterior (Fig. 7-D) aspect of the humerus and the glenoid.

If excessive posterior subluxation occurs when the arm is flexed (Fig. 7-E), consider an offset (eccentric) humeral head prosthesis with the larger aspect anteriorly (Fig. 7-F) and a rotator interval plication (Fig. 7-G). While the placement of the head eccentricity anteriorly may make it slightly prominent, we have not encountered problems with the subscapularis repair when we have used this approach to enhancing stability.

Ensure that the humeral articular surface lines up with the center of the reamed glenoid articular surface in the anteroposterior and superorinferior directions (Fig. 7-H).

Select the final prosthesis on the basis of this trialing and assemble it on the back table using new sterile gloves.

Irrigate the medullary canal with antibiotic-containing saline solution.

Using morcellized bone harvested from the resected humeral head and osteophytes, impact autograft into the canal utilizing an impactor of the same geometry as the definitive humeral stem (Fig. 8-A). Continue impaction until the impactor becomes snug—i.e., so that it cannot be completely seated by hand. The graft may be placed preferentially medial, lateral, anterior, or posterior to fine-tune the component position in the humerus.

Make six drill holes in the humerus so that they are through solid bone at the margin of the humeral neck cut, beginning at the top of the lesser tuberosity. This is important to avoid “pull-through” of the sutures from the bone.

Pass number-2 nonabsorbable sutures through each of the six holes (Fig. 8-B).

Irrigate the medullary canal with antibiotic-containing saline solution.

Using sterile gloves and insertion tools, seat the definitive prosthesis so that it achieves the desired superoinferior and anteroposterior relationship with the reamed glenoid.

Check again to be sure that there is no unwanted contact between bone of the medial or posterior aspect of the humerus and the glenoid (Figs. 7-C and 7-D).

Examine again the range of flexion (ideally it should be 150°), the range of internal rotation of the abducted arm (ideally 60°), and the posterior translation (ideally just less than 50% of the width of the glenoid) (Figs. 7-A and 7-B).

Determine again if the humeral head drops back out of the glenoid center with flexion (Fig. 7-E).

If the shoulder is too tight, consider additional soft-tissue releases or downsizing the humeral head height.

If the shoulder allows too much posterior translation, consider again a humeral head with greater width (Fig. 9) or anterior offset eccentricity (Fig. 7-F).

If the shoulder allows too much posterior translation, consider again a rotator interval plication (Fig. 7-G).

Repair the subscapularis tendon securely using the previously placed six sutures (Fig. 8-B).

Institute self-assisted flexion, with the patient using the contralateral hand while supine, a pulley, and/or forward lean on the day of the surgery or the next day³.

Institute self-assisted external rotation strengthening to support posterior stability.

Follow the patient’s range of motion closely for the first three months; if the range drops below 150° of flexion, consider increasing the vigor of the physical therapy or possibly a gentle manipulation under complete muscle relaxation.

Gently progress strengthening as comfort permits while maintaining the range of motion³.

A well-motivated, active, informed, and consenting patient who wishes to avoid the potential risks of plastic and cement and who understands the required dedication to rehabilitation, including that it may require more effort to maintain the range of motion during the healing period than that commonly experienced after total shoulder arthroplasty.

A shoulder with noninflammatory arthritis and a reconstructable anatomy. It should be noted that certain conditions—for example, glenoid dysplasia—may preclude reconstruction with the ream-and-run procedure.

A prosthesis instrument system that allows for concentric glenoid reaming, a press-fit humeral stem, and variations in humeral head curvature, height, and offset.

A recent history of smoking, narcotic use, depression, socioeconomic distress, and medicolegal or Workers’ Compensation issues. In our experience, individuals with these characteristics have had a poorer recovery from this procedure.

Poor physical or mental health.

Distortion of humeral or glenoid anatomy to the extent that reconstruction is very difficult.

Rotator cuff, deltoid, or neurological deficits.

A history of shoulder infection or other inflammatory arthropathy. A similar procedure can be used, however, for reimplanting a humeral component after an infection is treated with an antibiotic cement spacer.

Obtaining satisfactory glenoid exposure/preparation. Optimizing humeral head position with respect to the glenoid and soft-tissue balancing.

Failure to align the humeral head with the glenoid concavity.

Failure to remove abutting bone inferiorly or posteriorly.

Failure to adequately stabilize the humeral body by impaction autografting.

Failure to achieve a concentrically reamed glenoid.

Failure to achieve posterior stability through prosthesis selection, positioning, and soft-tissue balancing (including rotator interval plication).

Failure to monitor and ensure the range of motion during recovery. If the shoulder does not exhibit 150° of assisted elevation at four to six weeks after surgery, gentle manipulation under anesthesia and complete muscle relaxation can be considered.

What activity limitations should be placed on patients treated with a conventional total shoulder arthroplasty?

What options are available for patients who wish not to have these activity limitations?

What data are available regarding the short, intermediate, and long-term success of these options?