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Images shoulder.jpg view.jpg glenoid wear.jpg
  • summary
    • A shoulder hemiarthroplasty is a procedure in which the humeral articular surface is replaced with stemmed humeral component.
    • The most common indication is glenohumeral arthritis when the glenoid bone stock is inadequate for a total shoulder arthroplasty. 
    • It is contraindicated in patients with coracoacromial ligament deficiency.
  • Indications
    • Indications
      • primary arthritis, if:
        • rotator cuff is deficient
        • glenoid bone stock is inadequate
        • risk of glenoid loosening is high
          • young patients
          • active laborers
      • rotator cuff arthropathy
        • hemiarthroplasty > rTSA if able to achieve forward flexion > 90 degrees
      • osteonecrosis without glenoid involvement
      • proximal humerus fractures
        • three-part fractures with poor bone quality
        • four-part fractures
        • head-splitting fractures
        • fracture with significant destruction of the articular surface
    • Contraindications
      • infection
      • neuropathic joint
      • unmotivated patient
      • coracoacromial ligament deficiency
        • provides a barrier to humeral head proximal migration in the case of a rotator cuff tear
        • superior escape will occur if coracoacromial ligament and rotator cuff are deficient
  • Outcomes
    • Rotator cuff deficiency
      • status of the rotator cuff is the most influential factor affecting postoperative function in shoulder hemiarthroplasty
    • Proximal humerus fractures
      • provides excellent pain relief in a majority of patients
      • outcome scores inversely proportional to
        • patient age
        • time from injury to operation
  • Preoperative Imaging
    • Radiographs
      • true (Grashey) AP of shoulder
        • taken 30-40 degrees oblique to the coronal plane of the body
        • findings
          • helps determine extent of DJD
          • delineation of fracture pattern
      • axillary view
        • findings
          • look for posterior wear of glenoid
          • helps quantify displacement in cases of fracture
    • CT scan
      • obtain CT scan to determine glenoid version and glenoid bone stock
      • useful if fracture pattern is poorly understood after radiographic evaluation
    • MRI
      • useful for evaluation of rotator cuff
  • techniques
    • Approach
      • deltopectoral approach
    • Shaft preparation and prosthesis placement
      • humeral head resection
        • start osteotomy at medial insertion line of supraspinatus
      • determine retroversion, implant height and head size
        • retroversion
          • 30° of retroversion is ideal
          • lateral fin should be slightly posterior to biceps groove
          • excessive anteversion leads to risk of anterior dislocation
          • excessive retroversion leads to risk of posterior dislocation
        • implant height
          • greater tuberosity should be
            • 7 to 8 mm below the top of the prosthetic humeral head
              • functions to
                • maintain cuff and biceps tension
                • recreate normal contour of medial calcar
              • technique to achieve
                • cement prosthesis proud
                • distance from top of prosthesis head to upper border of pectoralis major should be 56mm.
        • head size
          • determine size by using
            • radiograph of contralateral shoulder or
            • measuring size of native head removed earlier in procedure
            • using too large of a head may "overstuff" joint
    • Fixation
      • cemented prosthesis
        • standard of care
        • provides better quality of life, range of motion, and strength compared to uncemented humeral component
    • Tuberosity reduction
      • introduction
        • tuberosity migration is one of the most common causes of failure for fractures treated with hemiarthroplasty
      • technique
        • strict attention to securing the tuberosities to each other and to the shaft
        • autogenous bone grafting from the excised humeral head will decrease the incidence of pull-off and improve healing rates
        • tuberosity reduction must be anatomic or it may lead to a deficit in rotation
    • The "Ream and Run" Procedure
      • introduction
        • shoulder hemiarthroplasty with concentric glenoid reaming (non-prosthetic glenoid arthroplasty)
        • avoids the potential limitations associated with a prosthetic glenoid component
        • provides patient with the opportunity for a level of activity beyond that recommended for a total shoulder arthroplasty
      • technique
        • spherical reaming of the osseous glenoid surface to optimize both glenohumeral stability and the distribution of load applied by the humeral prosthesis
        • the glenoid face is reamed to a single smooth concavity using a nubbed spherical reamer
      • outcomes
        • excellent functional and radiographic 2-year outcomes 
  • Rehab
    • Early passive motion until fracture has healed
      • duration usually 6-8 weeks
    • Strengthening exercises begin once tuberosity has fully healed
  • Complications
    • Progressive glenoid arthrosis
      • increased risk with
        • young patients
        • active patient
      • treatment
        • conversion to total shoulder arthroplasty
    • Tuberosity displacement/malunion
      • one of the most common complications of shoulder hemiarthroplasty when used to treat fracture
      • treatment
        • repositioning of the tuberosity with bone grafting
    • Joint overstuffing
      • may lead to
        • stiffness
        • accelerated arthritis of glenoid
    • Subcutaneous (anterosuperior) escape
      • occurs when both rotator cuff and coracoacromial arch are deficient
      • better outcomes with conversion to reverse shoulder arthroplasty compared to anatomic TSA
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