Orthopedics

Feature Article 

Return to Sport Following Hemiarthroplasty With Concentric Reaming Versus Total Shoulder Arthroplasty: A Matched Pair Analysis

Grant H. Garcia, MD; Anirudh K. Gowd, MD; Joseph N. Liu, MD; Marissa R. Malaret, BS; Brandon C. Cabarcas, MD; Anthony A. Romeo, MD

Abstract

The purpose of this study was to establish functional outcomes regarding return to sport activity for patients receiving anatomical total shoulder arthroplasty (aTSA) vs the ream and run procedure (hemi RR). Patients who underwent hemi RR and who underwent aTSA with a polyethylene glenoid component for end-stage glenohumeral arthritis were retrospectively identified from 2000 to 2014. Patients were matched regarding age, body mass index, sex, and hand dominance. Patients were surveyed to determine their level of sport and satisfaction after surgery. At a mean follow-up of 69.1±24.8 months, a total of 26 hemi RR and 30 aTSA patients met inclusion/exclusion criteria. Mean±SD age at the time of surgery was 53.0±8.5 years. There was no statistical difference between the two cohorts regarding patients who reported no postoperative problems (69.2% vs 76.7%, P=.529), reoperation (11.5% vs 6.7%, P=.522), return to overall sport (94.4% vs 86.4%, P=.395), return to high-demand upper-extremity sport (92.3% vs 81.3%, P=.390), and return to same or better level of intensity sport (83.3% vs 72.7%, P=.424). Patients returned to sport at a mean of 7.5±5.7 months and 6.2±3.6 months in the hemi RR and aTSA cohorts, respectively (P=.485). Radiographic measurements of medialization (mean, −2.4±5.0 vs −2.2±5.7; P=.913) and postoperative decentering (mean, 3.6%±2.6% vs 4.3%±3.3%; P=.795) were equivalent for the two cohorts. Hemi RR was found to have high and equivalent rates of sporting outcomes, clinical outcomes, and radiographic outcomes compared with aTSA. As appropriately indicated patients are counseled for surgery, realistic expectations regarding sports should be discussed. [Orthopedics. 201x; xx(x):xx–xx.]

Abstract

The purpose of this study was to establish functional outcomes regarding return to sport activity for patients receiving anatomical total shoulder arthroplasty (aTSA) vs the ream and run procedure (hemi RR). Patients who underwent hemi RR and who underwent aTSA with a polyethylene glenoid component for end-stage glenohumeral arthritis were retrospectively identified from 2000 to 2014. Patients were matched regarding age, body mass index, sex, and hand dominance. Patients were surveyed to determine their level of sport and satisfaction after surgery. At a mean follow-up of 69.1±24.8 months, a total of 26 hemi RR and 30 aTSA patients met inclusion/exclusion criteria. Mean±SD age at the time of surgery was 53.0±8.5 years. There was no statistical difference between the two cohorts regarding patients who reported no postoperative problems (69.2% vs 76.7%, P=.529), reoperation (11.5% vs 6.7%, P=.522), return to overall sport (94.4% vs 86.4%, P=.395), return to high-demand upper-extremity sport (92.3% vs 81.3%, P=.390), and return to same or better level of intensity sport (83.3% vs 72.7%, P=.424). Patients returned to sport at a mean of 7.5±5.7 months and 6.2±3.6 months in the hemi RR and aTSA cohorts, respectively (P=.485). Radiographic measurements of medialization (mean, −2.4±5.0 vs −2.2±5.7; P=.913) and postoperative decentering (mean, 3.6%±2.6% vs 4.3%±3.3%; P=.795) were equivalent for the two cohorts. Hemi RR was found to have high and equivalent rates of sporting outcomes, clinical outcomes, and radiographic outcomes compared with aTSA. As appropriately indicated patients are counseled for surgery, realistic expectations regarding sports should be discussed. [Orthopedics. 201x; xx(x):xx–xx.]

The incidence of total shoulder arthroplasty continues to rise at a considerable rate. By 2030, compared with current rates, the demand for total shoulder arthroplasty is projected to increase by 333% for patients younger than 55 years and 755.4% for patients older than 55 years.1 Concurrently, research regarding hemiarthroplasty with concentric glenoid reaming, the “ream and run” hemiarthroplasty, has demonstrated excellent functional outcomes at short-and long-term follow-up.2–7 Nearly 20% of patients undergoing shoulder arthroplasty have reported an improved ability to participate in sports as a very important outcome.8 However, limited studies have been performed regarding returning to sport following this procedure. Setting patient expectations is critical to achieving strong clinical outcomes and patient satisfaction in numerous orthopedic procedures, although further research is required to appropriately identify and counsel patients.8–11 Evaluating return to sport within this population is greatly beneficial for determining ideal candidates for this procedure and appropriately setting patient expectations.

Numerous glenoid pathologies exist that require correction, such as bone loss from instability, glenohumeral arthritis with osteophyte formation and subsequent retroversion or inferior tilt, and glenoid dysplasia.12–14 Glenoid resurfacing is reserved for these pathologies when the rotator cuff is intact and there is adequate bone stock for potential implantation.15 Ignoring the glenoid with only a humeral hemiarthroplasty has been reported to have clinical outcomes inferior to total shoulder arthroplasty and can frequently lead to future conversion to total shoulder arthroplasty.16–18 Proponents of hemiarthroplasty argue that survivorship concerns regarding the glenoid component may limit the longevity of the total shoulder arthroplasty, as symptomatic glenoid loosening may lead to a revision procedure or conversion to reverse shoulder arthroplasty.19,20 These are important considerations, particularly in active patients, as extensive mobility about the shoulder may allow for obligate translation of the humeral head on the glenoid as end range of motion is approached, resulting in the “rocking horse phenomenon” from repetitive edge loading, and subsequent glenoid component loosening.21

Hemiarthroplasty with concentric reaming resurfacing of the glenoid was first described to overcome the disadvantages of the glenoid component.6 Concentric reaming of the glenoid is able to address various aspects of glenoid pathology and is associated with positive short-and long-term clinical outcomes.3–7,22 It has been appropriately emphasized that patient selection is critical to the success of this operation and that it should be reserved for highly motivated and active populations.23 However, previous reports regarding return to sport following anatomical total shoulder arthroplasty (aTSA) have been highly favorable, with 85.1% to 97.3% of patients returning to sport and 72.3% to 85.0% of patients returning to an equivalent or improved level of play.24–26 Surprisingly, hemiarthroplasty without glenoid resurfacing has demonstrated inferior outcomes of 65.5% overall return to sport, significantly less return to overhead activities, and greater hindrance from activity.24 A long-term analysis of return to sport between appropriately matched patients receiving the ream and run procedure (hemi RR) vs aTSA would be greatly beneficial for determining differences in gain of function.

The purpose of this study was to determine whether patients who underwent hemiarthroplasty with glenoid resurfacing by concentric reaming achieved a high level of return to sport and had functional outcomes similar to those of a matched cohort of patients who underwent total shoulder arthroplasty. Secondarily, the authors sought to determine changes in function and satisfaction among patients requiring conversion to aTSA following hemi RR. The hypothesis was that patients receiving the ream and run procedure would return to sport at higher rates than and have outcomes equivalent to those receiving total shoulder arthroplasty.

Materials and Methods

Study Design

Following institutional review board approval, a prospectively maintained institutional registry was retrospectively queried for all patients who received a hemi RR and all patients who received an aTSA from 2000 to 2014. Patients with symptomatic glenohumeral osteoarthritis and intact rotator cuff tendons who received primary shoulder arthroplasty and had a minimum follow-up of 2 years were included. Patients with all other diagnoses, revision shoulder arthroplasty, and less than 2-year follow-up were excluded.

Population Cohorts

The hemi RR population was considerably smaller than the aTSA population because of specific indications for this procedure.23 Patients undergoing this procedure were questioned regarding their motivation to regain range of motion and their desire to return to a high level of functional activity after surgery. They were also questioned regarding preoperative use of opioids, with consistent users being excluded from hemi RR. Finally, radiographic analysis had to be consistent with significant glenoid pathology as diagnosed on radiographic imaging without substantial retroversion greater than 25° to allow for correction to 15° of retroversion or less (A1, A2, B1, early B2 based on the Walch classification). The resulting hemi RR cohort was matched to the aTSA cohort using the nearest neighbor method based on the following variables: age (±5 years), sex, body mass index, dominant extremity, and follow-up period (±6 months).

Surgical Technique

The surgical technique for the hemiarthroplasty with concentric glenoid reaming was performed similar to previous reports6,27 with few alterations. A set of glenoid reamers that were specifically designed for the system used for the humeral prosthesis were employed for every case. The key component of the reamer design was a reaming diameter exactly 2 mm larger than the anatomic head selected for the humeral replacement. For example, a 50-mm humeral head would result in a 52-mm concentric glenoid reamer to machine the glenoid socket, fixed on the glenoid center line with a 2.8-mm guide pin.28

The following surgical steps were the same between the hemi RR and the aTSA cohorts. The procedure was performed via the deltopectoral approach. The senior author (A.A.R.) switched from performing a subscapularis tenotomy to a subscapularis peel in 2013 for all patients receiving shoulder arthroplasty.29 The subscapularis was elevated from the lesser tuberosity and tagged with sutures for later reattachment. The subscapularis was reattached during closure through a transosseous repair. The humeral head was cut along the anatomic neck using an oscillating saw. The diameter of the anatomic neck was then matched with the appropriately sized humeral head trial prosthesis. Care was taken to remove all remnants of the typical circumferential osteophyte to most accurately determine the diameter of the humeral head. If the size was between two options, the smaller diameter head was selected. This also determined the size of the glenoid reamer for the hemi RR. The humeral canal was reamed and broached by hand to a secure stem fit to determine the appropriate stem size. Attention was turned to the glenoid. A stout 2.8-mm guide pin was placed in the glenoid center line as determined by preoperative assessment of radiographs and advanced imaging (computed tomography or magnetic resonance imaging). It was then visualized intraoperatively after the capsular release allowed a direct view and straight approach to the glenoid face.

At this stage, for the hemi RR patients, a glenoid reamer was used to resurface the glenoid until all cartilage was removed and a cancellous bony surface was achieved with appropriate concavity. The peripheral cortical bone of the glenoid was preserved as much as possible. If posterior wear beyond 15° but less than 25° was present, concentric reaming, involving reaming the anterior high side and creating a uniform concavity, was performed to correct up to 10° of retroversion back toward normal values. Among the hemi RR patients, the diameter of the humeral head was consistently 2 mm smaller than the concentric reaming to maximize surface contact area and provide an appropriate balance between stability and mobility as described previously.27 For patients undergoing a glenoid implant, the face of the glenoid was first prepared using a reamer that was significantly larger than the humeral head, designed with the concept of minimizing bone removal, including in the central vault of the glenoid. A pegged all-polyethylene glenoid component was machined with matching power instruments, the cement was pressurized into the peg holes, and then the component was impacted into the prepared glenoid bone and held until the cement had set.

Following management of the glenoid side, the procedure was completed with the implantation of the humeral component and suture fixation of the subscapularis tendon using either tendon-to-bone transosseous nonabsorbable sutures or transosseous nonabsorbable sutures that were passed through holes in the humeral prosthesis. Care was taken to perform an anatomic subscapularis repair, without closing the rotator interval, to avoid constriction of external rotation. The remaining layers where closed with absorbable sutures. The arm was immobilized in a sling with a small side pillow with a circumferential strap to avoid excessive rotation.

Rehabilitation

Following hemi RR and aTSA, patients are asked to use the sling for 6 weeks to protect the repair of the subscapularis. However, they are instructed and encouraged to come out of the sling and work on range of motion exercises daily. Passive to active range of motion is advanced as tolerated but restricted from active or resisted internal rotation or backward extension for the first 6 weeks to protect the subscapularis repair. At 6 to 12 weeks, range of motion is ambitiously advanced with expected goals of greater than 140° of elevation, 45° of external rotation, and steadily improving internal rotation. Resistant strengthening exercises beginning with isometrics and progressing to elastic bands are instituted for external rotation, forward flexion, abduction, and internal rotation, and a variety of scapular muscle strengthening movements are also instituted. After 3 to 12 months, resisted internal rotation and backward extension is advanced along with all other strengthening exercises using isometrics, light bands, and then weights. Range of motion is increased to greater than 160° of elevation, 60° of external rotation with the arm at the side, 60° of external rotation with abduction, and 45° of internal rotation in abduction. The patients are usually assisted with a supervised physical therapy program. However, a key component for maximizing their ability to achieve their potential range of motion is daily self-directed exercises, including passive stretching at end range. For those patients who participated in these activities preoperatively, advanced strengthening such as forced eccentric movements and plyometric movements including Olympic-style lifting are discouraged until 6 months postoperatively.

Data Collection

Forty-one consecutive hemi RR patients were screened and evaluated. In accordance with inclusion and exclusion criteria, 35 patients remained and were matched to patients who received aTSA. Following institutional review board approval, each patient was contacted via phone or email to complete a predetermined sport-related questionnaire (Figure A, available in the online version of this article).24,26,30–33 Fitness sports were categorized based on previous definitions by Wylde et al34 and Naal et al.35 Nature sports included hunting, fishing, shooting, boating, and/or horseback riding. These sports were grouped together because they were all determined to be lower-demand activities regarding the upper extremity (Table 1).36,37 Preoperative diagnosis, age, body mass index, sex, and comorbidities were confirmed via electronic medical record. Finally, radiographic parameters of medialization and centralization were evaluated from anteroposterior Grashey and axial shoulder radiographs.7,38 Medialization was evaluated by comparing the initial postoperative radiograph with that of the latest available follow-up (Figure 1). Centralization was evaluated by comparing the preoperative radiograph with that of the latest available follow-up (Figure 2). Two fellowship-trained orthopedic sports medicine surgeons (G.H.G., J.N.L.) who were blinded to patients' return to sport independently reviewed all radiographs and provided measurements. Pre- and postoperative clinical outcomes were also evaluated using the American Shoulder and Elbow Surgeons (ASES) score. Achievement of clinically significant outcomes (minimally clinically important difference and substantial clinical benefit) was also evaluated for both the hemi RR and the aTSA patients using values calculated from the current population employing the distribution method. The minimally clinically important difference was calculated within the authors' cohort because this value is dependent on population characteristics. The calculated minimally clinically important difference for the ASES score was 11.9, which was in agreement with previously defined values of 13.6 and 13.5 reported in the literature.39,40 A previously established threshold for substantial clinical benefit—36.6—was used in this study.39

Demographics of the Matched Patient Cohorts

Table 1:

Demographics of the Matched Patient Cohorts

Measurement of medialization of the humeral prosthesis from initial postoperative (A) and latest (B) follow-up. A perfect circle was fitted to the humeral component. A line was drawn from the superior and inferior lips of the glenoid to create line Z. Vertical and horizontal grids were overlaid onto the image. A parallel line X was drawn from the center of the perfect circle (Y) to the clavicle. Another parallel line W was drawn from the lateral edge of the acromion. The difference in distance between lines W and X (WX) was used to measure medialization between the initial postoperative and final postoperative radiographs. To limit bias of magnification and rotation, radiographs were incorporated into the analysis only if the arm was in neutral rotation, there was equal extension of the scapular neck, and the area of the perfect circle was equivalent.

Figure 1:

Measurement of medialization of the humeral prosthesis from initial postoperative (A) and latest (B) follow-up. A perfect circle was fitted to the humeral component. A line was drawn from the superior and inferior lips of the glenoid to create line Z. Vertical and horizontal grids were overlaid onto the image. A parallel line X was drawn from the center of the perfect circle (Y) to the clavicle. Another parallel line W was drawn from the lateral edge of the acromion. The difference in distance between lines W and X (WX) was used to measure medialization between the initial postoperative and final postoperative radiographs. To limit bias of magnification and rotation, radiographs were incorporated into the analysis only if the arm was in neutral rotation, there was equal extension of the scapular neck, and the area of the perfect circle was equivalent.

Radiographic measurements of posterior decentering on preoperative (A) and postoperative (B) standard axillary radiographs. A perfect circle is drawn using the articular surface of the humeral head (preoperative) and the humeral implant (postoperative), with point Z in the center of the circle. A line is then drawn connecting the anterior (A) and posterior (C) edges of the glenoid fossa (A–C). Line B–X is drawn perpendicular to and bisecting line A–C to create the glenoid center line. The diameter of the perfect circle is represented by line D–F, which is parallel to line A–C. The intersection between lines B–X and D–F is labeled point E. Posterior decentering is measured as the percentage of the humeral head perfect circle behind the glenoid center line, which is calculated as (line E–Z)/(line D–F)×100%.

Figure 2:

Radiographic measurements of posterior decentering on preoperative (A) and postoperative (B) standard axillary radiographs. A perfect circle is drawn using the articular surface of the humeral head (preoperative) and the humeral implant (postoperative), with point Z in the center of the circle. A line is then drawn connecting the anterior (A) and posterior (C) edges of the glenoid fossa (A–C). Line B–X is drawn perpendicular to and bisecting line A–C to create the glenoid center line. The diameter of the perfect circle is represented by line D–F, which is parallel to line A–C. The intersection between lines B–X and D–F is labeled point E. Posterior decentering is measured as the percentage of the humeral head perfect circle behind the glenoid center line, which is calculated as (line E–Z)/(line D–F)×100%.

Statistical Analysis

Statistical analysis was performed using RStudio software version 1.0.143 (R Foundation for Statistical Computing, Vienna, Austria). Power analysis was performed a priori using results from a prior study comparing total shoulder arthroplasty with hemiarthroplasty without glenoid resurfacing. The required sample size to demonstrate a statistical difference between return to sport outcomes was determined to be 28 patients. Given that hemiarthroplasty is not directly comparable with hemi RR, the maximum number of patients (ie, 70) was included. Continuous variables were differentiated using the Student's t test. Categorical variables were compared using the chi-square test with 2×2 contingency tables. Proportions were compared using a two-sample z test. Significance was set at P<.05.

Results

A total of 56 patients (80% of the matched cohort) were available for final follow-up. Mean age of the population when surgery was performed was 53.0±8.5 years. Mean total follow-up time was 69.1±24.8 months. Demographics were re-evaluated to ensure that matching was still appropriate (Table 1).

Reasons for undergoing shoulder arthroplasty were compared (Figure 3). Pain relief was the primary reason for undergoing both hemi RR (16 of 26 patients) and aTSA (17 of 30 patients) (P=.711). Significantly more patients in the aTSA group (8 of 30) reported undergoing surgery to improve motion than in the hemi RR group (1 of 26) (P=.019). Equivalent proportions of the aTSA cohort (4 of 30) and the hemi RR cohort (5 of 26) reported that their primary reason was to continue to stay active and engage in sports (P=.549).

Reasons for undergoing shoulder arthroplasty in the hemiarthroplasty with the ream and run procedure (A) and the anatomical total shoulder arthroplasty (B) cohorts.

Figure 3:

Reasons for undergoing shoulder arthroplasty in the hemiarthroplasty with the ream and run procedure (A) and the anatomical total shoulder arthroplasty (B) cohorts.

A majority of the patients in both cohorts reported that they had no problems postoperatively. There were 3 reoperations in the hemi RR group. One patient underwent arthroscopic glenohumeral debridement. Two patients were converted to a total shoulder arthroplasty at 123 months and 16 months postoperatively, respectively. The patient undergoing arthroscopic debridement reported dissatisfaction with surgery, while those with conversions to aTSA reported that they were fairly satisfied with surgery. One patient requiring conversion from hemi RR to aTSA participated in sports and was able to return to sporting activities, while the patient undergoing arthroscopic debridement was not able to return to normal sporting activities. In the aTSA cohort, 2 patients required reoperation. One required a subscapularis repair, while the other required a revision aTSA because of glenoid loosening. This patient required explantation of the glenoid component, including removal of cement from the glenoid vault. No further implant was placed. This patient was dissatisfied with his surgery. He did not participate in sports prior to surgery. The patient requiring subscapularis repair was unable to return to sports. There was no statistical difference between the two cohorts regarding patients who experienced postoperative chronic pain, instability, nerve injury, fracture, stiffness, or reoperation (P>.05) (Table 2).

Postoperative Outcomes of the Matched Patient Cohorts

Table 2:

Postoperative Outcomes of the Matched Patient Cohorts

Only 1 patient who was surveyed reported no participation in sports preoperatively. This patient was excluded from the analysis of sports. Overall return to sport and return to same or better level was 94% and 83%, respectively, for the hemi RR cohort (P=.395) and 86% and 73%, respectively, for the aTSA cohort (P=.424). The return to sports with high upper-extremity demand was 92.3% in the hemi RR cohort and 81.3% in the aTSA cohort (P=.390). The time required to return to activities was not statistically different between the cohorts (P=.485) (Table 2).

Satisfaction was equivalent regarding surgery (P=.920), return to sport (P=.395), and fitness level (P=.818) between the hemi RR and aTSA cohorts. One patient in the hemi RR cohort (3.8%) reported overall dissatisfaction, while none in the aTSA cohort reported dissatisfaction. Regarding return to sporting activities, 1 patient (3.8%) reported dissatisfaction with hemi RR, while 3 patients (10%) reported dissatisfaction with aTSA (Table 2). Both patients from the hemi RR group converted to aTSA reported satisfaction with surgery. In the aTSA cohort, the only patient requiring explantation reported dissatisfaction with surgery. Comparison of preoperative and postoperative ASES scores demonstrated statistical improvement following surgery for both cohorts (P<.001). Using predefined clinically significant threshold values for the ASES score, 84.6% of the hemi RR patients achieved minimally clinically important difference, while 90% of the aTSA patients achieved this. Regarding substantial clinical benefit, 46.2% of the patients in the hemi RR cohort achieved this threshold, while 63.3% in the aTSA cohort did. At latest follow-up, stiffness was reported by 5 patients (19.2%) in the hemi RR cohort and 6 patients (20.0%) in the aTSA cohort (P=.944) (Table 2).

Follow-up of radiographic measurements was available at a mean of 38.4±38.8 months after hemi RR and 37.3±25.1 months after aTSA (P=.901). Four patients were excluded (3 in the hemi RR cohort and 1 in the aTSA cohort) due to lack of usable radiographs owing to unavailability, inappropriate rotation, or inappropriate quality as outlined previously. Neither group experienced significant medialization of the humeral head component. The mean medialization was −2.4±5.0 mm for the hemi RR cohort and −2.2±5.7 mm for the aTSA cohort (P=.913). In the hemi RR cohort, the mean degree of retroversion, as determined by radiographs, was 4.0%±2.5% preoperatively and 3.6%±2.6% postoperatively (P=.542). In the aTSA cohort, this was found to be 5.6%±4.5% preoperatively and 4.3%±3.3% postoperatively (P=.228). There was no significant difference in retroversion between preoperative measurements (P=.303) and postoperative measurements (P=.795) for the aTSA and the hemi RR cohorts. The 2 patients from the hemi RR group who required conversion to aTSA were measured at latest radiograph prior to the revision procedure and did not demonstrate medialization (mean, −3.4 mm) or greater decentering (mean postoperative, 4.5%).

Return to sport by activity was also reported (Figure 4). For the hemi RR group, rates of return to sport were available for golf (100%), rowing (100%), bowling (66.7%), cycling (100%), swimming (57%), cross-country skiing (100%), running (80%), gym activity (80%), weight lifting (91.7%), softball (100%), downhill skiing (60%), basketball (33.3%), baseball (100%), martial arts (0%), hunting/shooting (0%), yoga (100%), and football (100%). For patients who underwent aTSA, rates of return to sport were available for golf (78.6%), bowling (100%), cycling (75%), swimming (75%), running (100%), gym activity (100%), weight lifting (100%), softball (66.7%), downhill skiing (100%), basketball (50%), hunting/shooting (100%), and yoga (100%).

Return to sport by activity for the hemiarthroplasty with the ream and run procedure cohort and the anatomical total shoulder arthroplasty cohort.

Figure 4:

Return to sport by activity for the hemiarthroplasty with the ream and run procedure cohort and the anatomical total shoulder arthroplasty cohort.

Discussion

Some hesitancy remains regarding performing either hemiarthroplasty or total shoulder arthroplasty within active, typically younger, patient populations because of prescribed restrictions in motion and maximum weight to be lifted and the perceived increased need for revision surgery.24,25,33,41,42 The ream and run procedure offers a potential alternative for young and active patients, eliminating the risk of glenoid loosening. The current study found equivalence between the two cohorts regarding lack of postoperative complaints (69% vs 77%), reoperation rates (12% vs 7%), return to sport (94% vs 86%), dissatisfaction (3.8% vs 0%), clinically significant outcomes (achieved minimally clinically important difference, 85% vs 90%), and radiographic measurements of decentering and medialization. The cohorts within the current population achieved similar primary goals of the surgical procedure regarding relief of pain and return to sport. Regarding sports, there was no significant difference in return to any particular activity. The hemi RR group returned to high-demand upper-extremity sports at a rate of 92% and the aTSA group returned at a rate of 81%; although not significant, there was a trend toward significance that may be confirmed in a larger sample. Additionally, these findings were at nearly 6 years after surgery. The findings of this study reflect the high level of return to sport achievable for patients following hemi RR, with limited restriction of activity and limited advancement of glenoid pathology in the long term.

Garcia et al24 reported significantly worse outcomes regarding return to sport when comparing patients who underwent hemiarthroplasty alone with those who underwent total shoulder arthroplasty. The hemiarthroplasty patients had inferior outcomes regarding overall return to sport (66% vs 73%), return to low demand sport (57% vs 96%), satisfaction with sport (58% vs 94%), and hindrance from sport (45% vs 13%).24 However, findings from the current study indicate improved return to sport in the hemi RR group and outcomes equivalent to those of the total shoulder arthroplasty group. The addition of concentric glenoid reaming appears to appropriately manage glenoid wear and symptoms, allowing the patients to return to a high level of activity. Initial research with canines regarding this procedure indicated that concentric reaming of the glenoid results in new bone formation with increased density of periarticular trabecular bone and augmented healing with a thick fibrocartilaginous tissue covering the surface.43 The current study is the first to demonstrate the effect of this technique toward gain of function and return to sporting activity.

Given the growing demand for total shoulder arthroplasty among patients younger than 55 years, glenoid wear is an important consideration.1 Studies have reported survivorship of polyethylene glenoid components as 74% to 84% at 12 years postoperatively and the average time to revision surgery as 9.3 years following the index procedure.44,45 Surgeons are apprehensive about resurfacing the glenoid with a glenoid component in patients who participate in a high level of activity or workload because of a greater incidence of glenoid loosening. However, the lack of glenoid resurfacing (hemiarthroplasty only) results in the progression of pain and arthritis, leading to a requirement for revision surgery at a rate that supersedes the rate of revision for glenoid component loosening.17,46,47 Within the 6-year period included in the current study, the authors found that 7% of the total shoulder arthroplasties required further operation. Further, 12% of the hemi RR cohort required return to the operating room, which is similar to the rate reported in the literature.3,22 In the current study, the time to re-operation following hemi RR was almost 6 years (mean, 69.5 months). Additionally, the conversion to aTSA in the hemi RR cohort did not require any explantation of a glenoid component and may be less involved because only the glenoid component must be installed.48 Two patients underwent this conversion, and they had high rates of satisfaction and sport activity despite the need for revision surgery. Conversely, revision procedures following aTSA, such as conversion to a reverse total shoulder arthroplasty, are technically more difficult, often requiring osteotomy of the humerus to remove the humeral stem and management of bone loss after removing the glenoid component.49 A larger sample with longer follow-up is necessary to establish the need for revision surgery in both cohorts and how this impacts the continued level of sport and satisfaction.33

Evidence of glenoid erosion is an additional consideration when performing either hemi RR or aTSA. Radiographic measurements of medialization have been established as a surrogate measurement for glenoid erosion, represented by medial migration of the humeral head.7,50 The current study found lateral movement of the humeral head in both the hemi RR and the aTSA cohorts, which has been reported previously. This may be due to either measurement error, inconsistencies in radiographic positioning, or fibrocartilaginous layering after resurfacing.7,50 In addition to removing osteophytes and improving glenoid concavity, the new fibrocartilage surface created during the healing process that follows the ream and run procedure may facilitate joint movement that is required for functional range of motion including the ability to play sport.43 Further research is required to demonstrate the presence of this layer, the histological characteristics of the tissue, and whether the presence of this tissue is accurately reflected by this radiographic measurement. This same measurement was performed for the aTSA cohort, which was found to have equivalent measurements of migration. The percentage of decentering also was not different between the hemi RR and aTSA cohorts or between preoperative and postoperative measurements. This reflects preselected characteristics of the pathoanatomy of these cohorts, as severely retroverted or dysplastic glenoids were not selected and there was no significant correction during the procedure.38 The clinical significance of both of these reproducible radiographic measurements is not well established,7,38,50 although there was no difference between the cohorts.

Patient selection based on both objective and subjective factors has been emphasized regarding the ream and run procedure.3–7,23 This procedure requires active, ambitious, and consistent participation by the patient with postoperative rehabilitation to achieve and maintain at least 150° of flexion with good external rotation strength.27 Therefore, the procedure is contraindicated for patients who are unmotivated, prioritizing secondary gain issues related to personal or work-related injury, addicted to narcotics, or of poor mental health.27,51 Surgeons do not need to restrict range of motion to after the subscapularis heals for patients receiving this procedure; the lack of a glenoid component removes the effects of edge loading and consequential early glenoid loosening.20 Additionally, this procedure may be inadvisable for patients with high degrees of retroversion if concentric reaming is likely to remove valuable bone stock.38,52 Ultimately, a minority of patients will be candidates for the ream and run procedure. This further corroborates the notion of the 4 Ps regarding operative management emphasized by Matsen23: right patient, right procedure, right physician, and right problem.

Limitations

The primary limitation of this study was its retrospective design. Matched cohorts were created retrospectively rather than prospectively enrolled. This may have introduced some bias because patients were matched based on demographic characteristics. To account for differences in reason for surgery, responses were collected with the patients' intent to undergo shoulder arthroplasty. Additionally, smaller differences between return to sport in these cohorts may be more appreciable with larger samples. Given that return to sport has not been quantified in the ream and run population, the a priori power analysis was performed using a prior study comparing hemiarthroplasty with total shoulder arthroplasty. The power was adequate for the purposes of this study. Additionally, although the follow-up period was long, results may change with even longer follow-up of 10+ years because glenoid components are expected to loosen in this period.

Conclusion

Compared with aTSA, hemi RR was found to have high or equivalent outcomes regarding return to sport, reoperation, satisfaction, clinical outcome measures, and medialization and decentralization as demonstrated on radiographs. As appropriately indicated patients are counseled for surgery, expectations regarding return to sport should be set. Hemiarthroplasty with concentric reaming offers a high level of return to sport with minimal glenoid wear. As such, it is an attractive alternative to total shoulder arthroplasty for younger patients with high levels of desired activity.

References

  1. Padegimas EM, Maltenfort M, Lazarus MD, Ramsey ML, Williams GR, Namdari S. Future patient demand for shoulder arthroplasty by younger patients: national projections. Clin Orthop Relat Res. 2015;473(6):1860–1867. doi:10.1007/s11999-015-4231-z [CrossRef]
  2. Matsen FA III, Tang A, Russ SM, Hsu JE. Relationship between patient-reported assessment of shoulder function and objective range-of-motion measurements. J Bone Joint Surg Am. 2017;99(5):417–426. doi:10.2106/JBJS.16.00556 [CrossRef]
  3. Somerson JS, Matsen FA III, . Functional outcomes of the ream-and-run shoulder arthroplasty: a concise follow-up of a previous report. J Bone Joint Surg Am. 2017;99(23):1999–2003. doi:10.2106/JBJS.17.00201 [CrossRef]
  4. Matsen FA III, Warme WJ, Jackins SE. Can the ream and run procedure improve glenohumeral relationships and function for shoulders with the arthritic triad?Clin Orthop Relat Res. 2015;473(6):2088–2096. doi:10.1007/s11999-014-4095-7 [CrossRef]
  5. Gilmer BB, Comstock BA, Jette JL, Warme WJ, Jackins SE, Matsen FA. The prognosis for improvement in comfort and function after the ream-and-run arthroplasty for glenohumeral arthritis: an analysis of 176 consecutive cases. J Bone Joint Surg Am. 2012;94(14):e102. doi:10.2106/JBJS.K.00486 [CrossRef]
  6. Clinton J, Franta AK, Lenters TR, Mounce D, Matsen FA III, . Nonprosthetic glenoid arthroplasty with humeral hemiarthroplasty and total shoulder arthroplasty yield similar self-assessed outcomes in the management of comparable patients with glenohumeral arthritis. J Shoulder Elbow Surg. 2007;16(5):534–538. doi:10.1016/j.jse.2006.11.003 [CrossRef]
  7. Somerson JS, Neradilek MB, Service BC, Hsu JE, Russ SM, Matsen FA III, . Clinical and radiographic outcomes of the ream-and-run procedure for primary glenohumeral arthritis. J Bone Joint Surg Am. 2017;99(15):1291–1304. doi:10.2106/JBJS.16.01201 [CrossRef]
  8. Swarup I, Henn CM, Nguyen JT, et al. Effect of pre-operative expectations on the outcomes following total shoulder arthroplasty. Bone Joint J.2017;99-B (9):1190–1196. doi:10.1302/0301-620X.99B9.BJJ-2016-1263.R1 [CrossRef]
  9. Gandhi R, Davey JR, Mahomed N. Patient expectations predict greater pain relief with joint arthroplasty. J Arthroplasty. 2009;24(5):716–721. doi:10.1016/j.arth.2008.05.016 [CrossRef]
  10. Soroceanu A, Ching A, Abdu W, McGuire K. Relationship between preoperative expectations, satisfaction, and functional outcomes in patients undergoing lumbar and cervical spine surgery: a multicenter study. Spine (Phila Pa 1976). 2012;37(2):E103–E108. doi:10.1097/BRS.0b013e3182245c1f [CrossRef]
  11. Mahomed NN, Liang MH, Cook EF, et al. The importance of patient expectations in predicting functional outcomes after total joint arthroplasty. J Rheumatol. 2002;29(6):1273–1279.
  12. Churchill RS, Brems JJ, Kotschi H. Glenoid size, inclination, and version: an anatomic study. J Shoulder Elbow Surg. 2001;10(4):327–332. doi:10.1067/mse.2001.115269 [CrossRef]
  13. Habermeyer P, Magosch P, Luz V, Lichtenberg S. Three-dimensional glenoid deformity in patients with osteoarthritis: a radiographic analysis. J Bone Joint Surg Am. 2006;88(6):1301–1307.
  14. Walch G, Badet R, Boulahia A, Khoury A. Morphologic study of the glenoid in primary glenohumeral osteoarthritis. J Arthroplasty. 1999;14(6):756–760. doi:10.1016/S0883-5403(99)90232-2 [CrossRef]
  15. Baumgarten KM, Lashgari CJ, Yamaguchi K. Glenoid resurfacing in shoulder arthroplasty: indications and contraindications. Instr Course Lect. 2004;53:3–11.
  16. Bryant D, Litchfield R, Sandow M, Gartsman GM, Guyatt G, Kirkley A. A comparison of pain, strength, range of motion, and functional outcomes after hemiarthroplasty and total shoulder arthroplasty in patients with osteoarthritis of the shoulder: a systematic review and meta-analysis. J Bone Joint Surg Am. 2005;87(9):1947–1956. doi:10.2106/JBJS.D.02854 [CrossRef]
  17. Radnay CS, Setter KJ, Chambers L, Levine WN, Bigliani LU, Ahmad CS. Total shoulder replacement compared with humeral head replacement for the treatment of primary glenohumeral osteoarthritis: a systematic review. J Shoulder Elbow Surg. 2007;16(4):396–402. doi:10.1016/j.jse.2006.10.017 [CrossRef]
  18. Edwards TB, Kadakia NR, Boulahia A, et al. A comparison of hemiarthroplasty and total shoulder arthroplasty in the treatment of primary glenohumeral osteoarthritis: results of a multicenter study. J Shoulder Elbow Surg. 2003;12(3):207–213. doi:10.1016/S1058-2746(02)86804-5 [CrossRef]
  19. Roberson TA, Bentley JC, Griscom JT, et al. Outcomes of total shoulder arthroplasty in patients younger than 65 years: a systematic review. J Shoulder Elbow Surg. 2017;26(7):1298–1306. doi:10.1016/j.jse.2016.12.069 [CrossRef]
  20. Pinkas D, Wiater B, Wiater JM. The glenoid component in anatomic shoulder arthroplasty. J Am Acad Orthop Surg. 2015;23(5):317–326. doi:10.5435/JAAOS-D-13-00208 [CrossRef]
  21. Collins D, Tencer A, Sidles J, Matsen F III, . Edge displacement and deformation of glenoid components in response to eccentric loading: the effect of preparation of the glenoid bone. J Bone Joint Surg Am. 1992;74(4):501–507. doi:10.2106/00004623-199274040-00005 [CrossRef]
  22. Saltzman MD, Chamberlain AM, Mercer DM, Warme WJ, Bertelsen AL, Matsen FA III, . Shoulder hemiarthroplasty with concentric glenoid reaming in patients 55 years old or less. J Shoulder Elbow Surg. 2011;20(4):609–615. doi:10.1016/j.jse.2010.08.027 [CrossRef]
  23. Matsen FA III, . The ream and run: not for every patient, every surgeon or every problem. Int Orthop. 2015;39(2):255–261. doi:10.1007/s00264-014-2641-2 [CrossRef]
  24. Garcia GH, Liu JN, Mahony GT, et al. Hemiarthroplasty versus total shoulder arthroplasty for shoulder osteoarthritis: a matched comparison of return to sports. Am J Sports Med. 2016;44(6):1417–1422. doi:10.1177/0363546516632527 [CrossRef]
  25. Liu JN, Steinhaus ME, Garcia GH, et al. Return to sport after shoulder arthroplasty: a systematic review and meta-analysis. Knee Surg Sports Traumatol Arthrosc. 2018;26(1):100–112. doi:10.1007/s00167-017-4547-1 [CrossRef]
  26. Garcia GH, Liu JN, Sinatro A, et al. High satisfaction and return to sports after total shoulder arthroplasty in patients aged 55 years and younger. Am J Sports Med. 2017;45(7):1664–1669. doi:10.1177/0363546517695220 [CrossRef]
  27. Matsen F III, Lippitt SB. Current technique for the ream-and-run arthroplasty for glenohumeral osteoarthritis. J Bone Joint Surg Am. 2012;2(4):e20.
  28. Bicos J, Mazzocca A, Romeo AA. The glenoid center line. Orthopedics. 2005;28(6):581–585.
  29. Van Thiel GS, Wang VM, Wang FC, et al. Bio-mechanical similarities among subscapularis repairs after shoulder arthroplasty. J Shoulder Elbow Surg. 2010;19(5):657–663. doi:10.1016/j.jse.2010.01.014 [CrossRef]
  30. Liu JN, Wu HH, Garcia GH, Kalbian IL, Strickland SM, Shubin Stein BE. Return to sports after tibial tubercle osteotomy for patellofemoral pain and osteoarthritis. Arthroscopy. 2018;34(4):1022–1029. doi:10.1016/j.arthro.2017.09.021 [CrossRef]
  31. Garcia GH, Wu HH, Liu JN, Huffman GR, Kelly JD IV, . Outcomes of the remplissage procedure and its effects on return to sports: average 5-year follow-up. Am J Sports Med. 2016;44(5):1124–1130. doi:10.1177/0363546515626199 [CrossRef]
  32. Garcia GH, Taylor SA, DePalma BJ, et al. Patient activity levels after reverse total shoulder arthroplasty: what are patients doing?Am J Sports Med. 2015;43(11):2816–2821. doi:10.1177/0363546515597673 [CrossRef]
  33. Garcia GH, Mahony GT, Fabricant PD, et al. Sports- and work-related outcomes after shoulder hemiarthroplasty. Am J Sports Med. 2016;44(2):490–496. doi:10.1177/0363546515613077 [CrossRef]
  34. Wylde V, Blom A, Dieppe P, Hewlett S, Lear-month I. Return to sport after joint replacement. J Bone Joint Surg Br. 2008;90(7):920–923. doi:10.1302/0301-620X.90B7.20614 [CrossRef]
  35. Naal FD, Fischer M, Preuss A, et al. Return to sports and recreational activity after unicompartmental knee arthroplasty. Am J Sports Med. 2007;35(10):1688–1695. doi:10.1177/0363546507303562 [CrossRef]
  36. Zarkadas PC, Throckmorton TQ, Dahm DL, Sperling J, Schleck CD, Cofield R. Patient reported activities after shoulder replacement: total and hemiarthroplasty. J Shoulder Elbow Surg. 2011;20(2):273–280. doi:10.1016/j.jse.2010.06.007 [CrossRef]
  37. Bülhoff M, Sattler P, Bruckner T, Loew M, Zeifang F, Raiss P. Do patients return to sports and work after total shoulder replacement surgery?Am J Sports Med. 2015;43(2):423–427. doi:10.1177/0363546514557940 [CrossRef]
  38. Service BC, Hsu JE, Somerson JS, Russ SM, Matsen FA III, . Does postoperative glenoid retroversion affect the 2-year clinical and radiographic outcomes for total shoulder arthroplasty?Clin Orthop Relat Res. 2017;475(11):2726–2739. doi:10.1007/s11999-017-5433-3 [CrossRef]
  39. Werner BC, Chang B, Nguyen JT, Dines DM, Gulotta LV. What change in American Shoulder and Elbow Surgeons score represents a clinically important change after shoulder arthroplasty?Clin Orthop Relat Res. 2016;474(12):2672–2681. doi:10.1007/s11999-016-4968-z [CrossRef]
  40. Simovitch R, Flurin PH, Wright T, Zuckerman JD, Roche CP. Quantifying success after total shoulder arthroplasty: the minimal clinically important difference. J Shoulder Elbow Surg. 2018;27(2):298–305. doi:10.1016/j.jse.2017.09.013 [CrossRef]
  41. Hurwit DJ, Liu JN, Garcia GH, et al. A comparative analysis of work-related outcomes after humeral hemiarthroplasty and reverse total shoulder arthroplasty. J Shoulder Elbow Surg. 2017;26(6):954–959. doi:10.1016/j.jse.2016.10.004 [CrossRef]
  42. Liu JN, Garcia GH, Mahony G, et al. Sports after shoulder arthroplasty: a comparative analysis of hemiarthroplasty and reverse total shoulder replacement. J Shoulder Elbow Surg. 2016;25(6):920–926. doi:10.1016/j.jse.2015.11.003 [CrossRef]
  43. Matsen FA III, Clark JM, Titelman RM, et al. Healing of reamed glenoid bone articulating with a metal humeral hemiarthroplasty: a canine model. J Orthop Res. 2005;23(1):18–26. doi:10.1016/j.orthres.2004.06.019 [CrossRef]
  44. Gauci MO, Bonnevialle N, Moineau G, Baba M, Walch G, Boileau P. Anatomical total shoulder arthroplasty in young patients with osteoarthritis: all-polyethylene versus metal-backed glenoid. Bone Joint J.2018;100-B(4):485–492. doi:10.1302/0301-620X.100B4.BJJ-2017-0495.R2 [CrossRef]
  45. Sperling JW, Cofield RH, Rowland CM. Minimum fifteen-year follow-up of Neer hemiarthroplasty and total shoulder arthroplasty in patients aged fifty years or younger. J Shoulder Elbow Surg. 2004;13(6):604–613. doi:10.1016/j.jse.2004.03.013 [CrossRef]
  46. van den Bekerom MP, Geervliet PC, Somford MP, van den Borne MP, Boer R. Total shoulder arthroplasty versus hemiarthroplasty for glenohumeral arthritis: a systematic review of the literature at long-term follow-up. Int J Shoulder Surg. 2013;7(3):110–115. doi:10.4103/0973-6042.118915 [CrossRef]
  47. Getz CL, Kearns KA, Padegimas EM, Johnston PS, Lazarus MD, Williams GR Jr, . Survivorship of hemiarthroplasty with concentric glenoid reaming for glenohumeral arthritis in young, active patients with a biconcave glenoid. J Am Acad Orthop Surg. 2017;25(10):715–723. doi:10.5435/JAAOS-D-16-00019 [CrossRef]
  48. Cheung EV, Sperling JW, Cofield RH. Revision shoulder arthroplasty for glenoid component loosening. J Shoulder Elbow Surg. 2008;17(3):371–375. doi:10.1016/j.jse.2007.09.003 [CrossRef]
  49. Crosby LA, Wright TW, Yu S, Zuckerman JD. Conversion to reverse total shoulder arthroplasty with and without humeral stem retention: the role of a convertible-platform stem. J Bone Joint Surg Am. 2017;99(9):736–742. doi:10.2106/JBJS.16.00683 [CrossRef]
  50. Mercer DM, Gilmer BB, Saltzman MD, Bertelsen A, Warme WJ, Matsen FA III, . A quantitative method for determining medial migration of the humeral head after shoulder arthroplasty: preliminary results in assessing glenoid wear at a minimum of two years after hemiarthroplasty with concentric glenoid reaming. J Shoulder Elbow Surg. 2011;20(2):301–307. doi:10.1016/j.jse.2010.03.010 [CrossRef]
  51. Werner BC, Wong AC, Chang B, et al. Depression and patient-reported outcomes following total shoulder arthroplasty. J Bone Joint Surg Am.2017;99(8):688–695. doi:10.2106/JBJS.16.00541 [CrossRef]
  52. Hsu JE, Gee AO, Lucas RM, Somerson JS, Warme WJ, Matsen FA III, . Management of intraoperative posterior decentering in shoulder arthroplasty using anteriorly eccentric humeral head components. J Shoulder Elbow Surg. 2016;25(12):1980–1988. doi:10.1016/j.jse.2016.02.027 [CrossRef]

Demographics of the Matched Patient Cohorts

CharacteristicHemi RR Cohort (N=26)aTSA Cohort (N=30)P
Age at surgery, mean±SD, y53.1±7.753.6±9.0.817
Body mass index, mean±SD, kg/m228.5±3.431.2±5.7.065
Follow-up, mean±SD, mo68.5±23.769.7±26.0.866
Previous procedures, mean±SD, No.0.4±0.60.4±0.6.968
Sex, male:female, No.24:227:3.764
Preoperative ASES score, mean±SD48.0±13.942.2±14.4.093

Postoperative Outcomes of the Matched Patient Cohorts

OutcomeHemi RR CohortaTSA CohortP
Failures and reoperation, No. (%)
  No problems18 (69.2)23 (76.7).529
  Chronic pain3 (11.5)1 (3.3).234
  Unstable1 (3.8)0 (0).280
  Nerve injury0 (0)2 (6.7).180
  Fracture0 (0)1 (3.3).347
  Stiffness5 (19.2)6 (20.0).944
  Reoperation3 (11.5)2 (6.7).522
Sports
  Return to sport, No./total no. (%)17/18 (94.4)19/22 (86.4).395
  Same/better level of intensity, No./total no. (%)15/18 (83.3)16/22 (72.7).424
  Return to high-demand upper-extremity sport, No./total no. (%)12/13 (92.3)13/16 (81.3).390
  Time to return to sport, mean±SD, mo7.5±5.76.2±3.6.485
  Feel hindrance from activity, No./total no. (%)7/26 (26.9)10/30 (33.3).603
Satisfaction
  Good/excellent satisfaction with surgery, No./total no. (%)17/26 (65.4)20/30 (66.7).920
  Good/excellent satisfaction with return to sport, No./total no. (%)20/26 (76.9)20/30 (66.7).395
  Good/excellent satisfaction with fitness level, No./total no. (%)23/26 (88.5)24/30 (80.0).818
Patient-reported outcome measures
  Postoperative SF-MCS, mean±SD54.3±8.255.0±9.4.795
  Postoperative SF-PCS, mean±SD49.2±9.746.4±10.0.303
  Delta ASES score, mean±SD36.8±23.840.9±23.9.531
  Achieved MCID, No./total no. (%)22/26 (84.6)27/30 (90.0).542
  Achieved SCB, No./total no. (%)12/26 (46.2)19/30 (63.3).197
Radiographic parameters, mean±SD
  Medialization, mm−2.4±5.0−2.2±5.7.913
  Preoperative decentering4.0%±2.5%5.6%±4.5%.303
  Postoperative decentering3.6%±2.6%4.3%±3.3%.795
Authors

The authors are from Seattle Orthopedic Center (GHG), Seattle, Washington; Wake Forest University Baptist Medical Center (AKG), Winston-Salem, North Carolina; Loma Linda University Medical Center (JNL), Loma Linda, California; Rush University Medical Center (MRM), Chicago, Illinois; University of South Florida Health (BCC), Tampa, Florida; and the Rothman Institute (AAR), New York, New York.

Dr Garcia, Dr Gowd, Dr Liu, Ms Malaret, and Dr Cabarcas have no relevant financial relationships to disclose. Dr Romeo is a paid consultant for Arthrex, Inc; has received research support from Aesculap/B Braun, Arthrex, Inc, Histogenics, Medipost, NuTech, OrthoSpace, Smith & Nephew, and Zimmer; receives royalties from Arthrex, Inc; and has received financial support from Major League Baseball.

Correspondence should be addressed to: Anirudh K. Gowd, MD, Wake Forest University Baptist Medical Center, 1 Medical Center Blvd, Winston-Salem, NC 27157 ( akgowd90@gmail.com).

Received: February 25, 2019
Accepted: June 03, 2019
Posted Online: July 02, 2019

10.3928/01477447-20190627-05

Sign up to receive

Journal E-contents