Updated: 6/6/2021

Shoulder Hemiarthroplasty

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Questions
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Evidence
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Techniques
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https://upload.orthobullets.com/topic/3074/images/posterior 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
  • 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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Questions (5)

(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
FIGURES:
1

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

10%

(178/1767)

2

Humeral head revision and placement of prosthetic glenoid component

54%

(949/1767)

3

Two-stage revision with placement of an antibiotic spacer

5%

(87/1767)

4

Revision total shoulder arthroplasty with a cemented humeral stem

17%

(293/1767)

5

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

14%

(240/1767)

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
1

The integrity of the rotator cuff

91%

(2725/3001)

2

The integrity of the coracoacromial ligament

3%

(81/3001)

3

The presence of glenoid wear

5%

(151/3001)

4

The presence of an inferior head osteophyte

0%

(5/3001)

5

The extent of AC joint arthritis

1%

(23/3001)

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
1

external rotation deficit

74%

(1402/1900)

2

internal rotation deficit

24%

(449/1900)

3

multi-directional instability

1%

(12/1900)

4

forward elevation weakness

1%

(12/1900)

5

elbow flexion weakness

1%

(19/1900)

L 2 C

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EXPERT COMMENTS (21)
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