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  • 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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(OBQ17.58) A 67-year-old male presents with left shoulder pain. He underwent surgery on his left shoulder 10 years prior. Initially, he was pain-free following surgery, however, his pain has returned and has been increasing in intensity. On physical examination, his incision is healed with no erythema. He actively exhibits 120° of forward flexion, 25° of external rotation, and internal rotation to L3. He exhibits 5/5 strength with forward flexion, internal rotation, and external rotation. He has a negative belly-press test, negative hornblower's sign, and a negative Spurling's test. Distally, he is neurovascularly intact. Joint aspiration is performed in the office and reveals a white blood cell count (WBC) of 1900 x10^9/L, with 20% polymorphonuclear leukocytes (PMNs). Cultures were held for 3 weeks and exhibited no growth to date. Radiographs are obtained and shown in Figures A & B. Which of the following is the next best step in the treatment of this patient?

QID: 210145

Magnetic resonance imaging (MRI) of the shoulder to evaluate the rotator cuff



Humeral head revision and placement of prosthetic glenoid component



Two-stage revision with placement of an antibiotic spacer



Revision total shoulder arthroplasty with a cemented humeral stem



Revision to an implant with a center of rotation that is moved infero-medially



L 4 B

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(SBQ07SM.21) A 60-year-old man has chronic shoulder pain and weakness. Radiographs show moderate glenohumeral arthritis and narrowing of the acromio-humeral distance. He is scheduled to undergo either hemiarthroplasty or total shoulder arthroplasty. His postoperative function will be most affected by which of the following factors?

QID: 1406

The integrity of the rotator cuff



The integrity of the coracoacromial ligament



The presence of glenoid wear



The presence of an inferior head osteophyte



The extent of AC joint arthritis



L 1 C

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(OBQ05.137) A 78-year old female sustained a 4-part proximal humerus fracture on her dominant side 2 days ago and undergoes a shoulder hemiarthroplasty. Intraoperatively, the lesser tuberosity reduction was difficult and placed too close to the greater tuberosity, which was anatomic. What post-operative problem is likely to result due to the position of the lesser tuberosity?

QID: 1023

external rotation deficit



internal rotation deficit



multi-directional instability



forward elevation weakness



elbow flexion weakness



L 2 C

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Evidence (19)
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