import { OnePagerSummary, ExamWarning, InfoCardGrid, InfoCard, MnemonicCard, EvidenceCard, VivaScenarioSection, VivaScenario, ExamCheatSheet, ContentSection, ExamPearl, SafetyAlert, NumberHighlightRow, NumberHighlight, Tabs, Tab, ComparisonTable } from '@/components/mdx' **Location**: Exits quadrangular space, runs 5-7cm inferior to lateral acromion edge, winds around surgical neck of humerus with posterior circumflex humeral artery **Protection**: Avoid dissection >5cm below acromion inferior edge, gentle inferior capsular release only, identify and protect during humeral preparation **Location**: Penetrates conjoint tendon (coracobrachialis) 5-8cm distal to coracoid tip, variable anatomy (3-10cm range) **Protection**: Avoid aggressive medial retraction of conjoint tendon, minimal dissection medial to conjoint, gentle retractor placement **Location**: "Three sisters" - run horizontally along inferior border of subscapularis tendon, 3 small arteries typically present **Protection**: Identify and ligate/cauterize before subscapularis release to prevent bleeding that obscures surgical field **Location**: Runs in deltopectoral groove, marks the interval between deltoid and pectoralis major, lateral tributaries from deltoid, medial from pectoralis **Protection**: Retract LATERAL with deltoid (preserves lateral tributaries), do not ligate (risk of DVT), gentle handling **Location**: Travel with axillary nerve through quadrangular space, wind around surgical neck posteriorly **Protection**: Gentle humeral manipulation, avoid aggressive circumferential dissection around neck, bleeding indicates nerve proximity ## Primary Indications ### Trauma Indications - **Acute 3-4 part proximal humerus fracture** in elderly patients (>65-70 years) - Head split pattern or severe comminution - Concern for AVN risk with ORIF - **NOTE**: Trend toward reverse TSA over hemiarthroplasty in most elderly fracture cases - **Failed ORIF** of proximal humerus fracture with: - Humeral head collapse/AVN - Articular incongruity - Symptomatic malunion/nonunion ### Elective Indications - **Primary glenohumeral osteoarthritis** with: - Intact rotator cuff - Glenoid bone loss or erosion (insufficient for anatomic TSA) - Patient preference to avoid glenoid component - **Avascular necrosis** of humeral head: - Preserved glenoid cartilage - Humeral head collapse (Ficat stage 3-4) - **Rheumatoid arthritis** (selected cases): - Intact rotator cuff - Severe humeral head destruction, glenoid relatively preserved ### Contraindications **Absolute:** - Active infection (shoulder or systemic) - Neurologic dysfunction (axillary nerve, complete brachial plexopathy) - Insufficient bone stock for component fixation - Medical comorbidities precluding surgery **Relative:** - Rotator cuff deficiency (consider reverse TSA instead) - Young active patient with high demands (reverse TSA may be better long-term) - Severe glenoid wear (will progress, consider anatomic or reverse TSA) - Non-compliance with rehabilitation protocol ## Preoperative Planning **Standard radiographs**: True AP (Grashey view), scapular Y, axillary lateral **CT scan**: Essential for fractures - assess head split, comminution, tuberosity displacement, glenoid involvement. For elective cases - assess glenoid version and bone stock **MRI**: If AVN suspected (marrow signal changes), assess rotator cuff integrity Measure native humeral head diameter (typically 42-50mm), assess humeral canal diameter and morphology, determine stem size (avoid over-sizing in osteoporotic bone), assess for varus/valgus deformity **Hemiarthroplasty vs Reverse TSA** (for fracture): - Reverse: elderly (>70-75), low demand, uncertain tuberosity healing potential - Hemiarthroplasty: younger (<70), good bone quality, high likelihood of tuberosity healing **Component selection**: Cemented vs press-fit based on bone quality ## Equipment Required ### Implants - Shoulder hemiarthroplasty system (cemented or uncemented stem options) - Modular humeral heads (range 40-56mm diameter, various eccentricities) - Bone cement (PMMA) if cementing - Cement restrictor ### Instruments - Shoulder arthroplasty instrument set - Humeral canal reamers and broaches - Head resection guide/cutting blocks - Stem insertion instruments - Trial components (stems and heads) ### Fixation Materials - Heavy non-absorbable sutures: #5 Ethibond (tuberosity-to-tuberosity) - #2 FiberWire or Ethibond (subscapularis, cerclage) - 18-gauge wire (cerclage, if preferred) - Small fragment plates/screws (if greater tuberosity plate augmentation planned) ## Surface Anatomy & Landmarks ### Key Surface Landmarks - **Acromion**: Palpable lateral edge - measure 5-7cm inferiorly (axillary nerve zone) - **Coracoid process**: Palpable through deltopectoral fat - starting point for incision - **Deltopectoral groove**: Palpable depression between muscle bellies - marks incision line - **Clavicle**: Medial border of incision reference ## Neurovascular Danger Zones ### Axillary Nerve (C5, C6) **Anatomic course**: - Motor branch from posterior cord of brachial plexus - Exits quadrangular space with posterior circumflex humeral artery - Winds around surgical neck of humerus posteriorly - **Critical distance**: 5-7cm inferior to lateral acromion edge (range 3-9cm) - Anterior and posterior branches (anterior to deltoid, posterior to skin) **At-risk maneuvers**: - Inferior capsular release - Humeral neck osteotomy in fractures - Inferior retractor placement - Circumferential dissection of humeral neck **Clinical consequence if injured**: Deltoid paralysis (cannot abduct arm), sensory loss lateral arm (regimental badge area), poor functional outcome ### Musculocutaneous Nerve (C5, C6, C7) **Anatomic course**: - Terminal branch from lateral cord - Penetrates conjoint tendon (coracobrachialis muscle) 5-8cm distal to coracoid tip - **Highly variable** - can be 3-10cm from coracoid - Travels between biceps and brachialis in arm **At-risk maneuvers**: - Aggressive medial retraction of conjoint tendon - Medial dissection beyond conjoint - Deep retractor placement medially **Clinical consequence if injured**: Weak elbow flexion (biceps and brachialis paralysis), sensory loss lateral forearm (lateral antebrachial cutaneous nerve) ### Cephalic Vein **Anatomic course**: - Superficial vein in deltopectoral groove - Lateral tributaries from deltoid muscle - Medial tributaries from pectoralis major - Drains to axillary vein proximally **Surgical approach**: Retract LATERAL with deltoid - preserves lateral tributaries (more robust), reduces risk of thrombosis **Clinical consequence if injured**: Bleeding (controllable), potential arm DVT if ligated ### Anterior Circumflex Humeral Vessels ("Three Sisters") **Anatomic course**: - Branch from axillary artery (third part) - Run HORIZONTALLY along inferior border of subscapularis tendon - Typically 3 small arteries (hence "three sisters") - Anastomose with posterior circumflex humeral artery **Surgical management**: Identify and ligate/cauterize BEFORE subscapularis release **Clinical consequence if injured**: Obscuring bleeding in surgical field, landmark for axillary nerve (just inferior) ### Posterior Circumflex Humeral Vessels **Anatomic course**: - Branch from axillary artery (third part) - Travel WITH axillary nerve through quadrangular space - Wind around surgical neck posteriorly **At-risk maneuvers**: Aggressive humeral manipulation, circumferential neck dissection ## Rotator Cuff Anatomy ### Subscapularis - **Origin**: Subscapular fossa of scapula - **Insertion**: Lesser tuberosity of humerus - **Function**: Internal rotation, anterior stabilizer - **Nerve supply**: Upper and lower subscapular nerves (C5, C6) - **Surgical relevance**: Must be released and repaired - critical for preventing anterior instability ### Rotator Interval - Space between subscapularis (inferior) and supraspinatus (superior) - Contains coracohumeral ligament and superior glenohumeral ligament - Long head biceps tendon passes through - Surgical entry point to joint ### Tuberosities (Trauma Cases) - **Greater tuberosity**: Supraspinatus, infraspinatus, teres minor attachments - **Lesser tuberosity**: Subscapularis attachment - Critical to preserve soft tissue attachments for healing potential ## Positioning and Preparation **Patient position**: Beach chair position (70-80° head elevation) - Entire shoulder, chest wall, arm to hand exposed - Arm free-draped (allows manipulation, extension for canal preparation) - Head secured in head holder - Ensure ability to extend and externally rotate arm **Anesthesia**: General with regional block (interscalene typically) **Antibiotics**: IV cefazolin (or vancomycin if MRSA risk) within 60 minutes **Positioning pearls**: - Table break at level of scapula allows extension - Ensure adequate medial exposure (avoid table obstruction) - Arm holder may be useful but free arm preferred by many --- ## Operative Steps - Complete Sequence ### Step 1: Skin Incision and Superficial Dissection **Incision**: - Start at coracoid process - Extend 12-15cm distally along deltopectoral groove - Aim toward lateral border of deltoid insertion - Can palpate groove as depression between muscle masses **Technique**: - Incise skin, subcutaneous tissue - Identify cephalic vein in deltopectoral groove - **KEY DECISION**: Retract vein LATERAL with deltoid - Preserves lateral tributaries (more robust than medial) - Reduces risk of thrombosis - Alternative: take vein medially (less common) or ligate (avoid if possible) **Exam Answer**: "I make a deltopectoral incision from the coracoid extending 12-15cm distally. I identify the cephalic vein marking the interval. I retract it LATERAL with the deltoid - this preserves the lateral tributaries and reduces thrombosis risk. I develop the deltopectoral interval bluntly." - Incision too lateral = through deltoid muscle (damage to muscle, axillary nerve risk) - Incision too medial = poor exposure, conjoint tendon injury - Cephalic vein injury = bleeding, DVT risk if ligated - Inadequate skin exposure = poor visualization, increased retraction force --- ### Step 2: Deep Dissection - Expose Rotator Cuff **Technique**: - Incise clavipectoral fascia lateral to conjoint tendon - Place self-retaining retractors: - Deltoid retracted LATERALLY - Conjoint tendon (coracobrachialis + short head biceps) retracted MEDIALLY - Identify subscapularis tendon (large tendon extending to lesser tuberosity) - Identify rotator interval (superior - between subscapularis and supraspinatus) - Identify long head biceps tendon in bicipital groove (if intact) **Anatomic orientation**: - Subscapularis is large anterior cuff tendon - Biceps tendon marks lateral border of rotator interval - Feel for coracoid medially (protect musculocutaneous nerve) **Exam Answer**: "I incise the clavipectoral fascia and place retractors - deltoid lateral, conjoint medial. I protect the musculocutaneous nerve which enters the conjoint 5-8cm from the coracoid. I identify subscapularis - the large anterior cuff tendon. The rotator interval is superior, and I can see the biceps tendon in its groove." - Musculocutaneous nerve injury - avoid aggressive medial retraction of conjoint tendon - Axillary nerve - lies 5-7cm below acromion, avoid inferior dissection at this stage - Anterior circumflex vessels - at inferior subscapularis border (not yet exposed) - Biceps tendon injury - if tenodesing, do so deliberately (don't avulse accidentally) --- ### Step 3: Subscapularis Management **For TRAUMA cases**: - Subscapularis often torn/avulsed with lesser tuberosity fragment - Identify lesser tuberosity fragment and tag with strong suture (#2 FiberWire) - Preserve all soft tissue attachments to fragments - Identify greater tuberosity fragment and tag similarly **For ELECTIVE cases** - two options: **Option A - Subscapularis tenotomy**: - Release subscapularis tendon 1cm from insertion on lesser tuberosity - Tag with two #2 FiberWire sutures (medial-lateral mattress) - Easier repair, less bone healing required - Risk: tendon retraction, repair failure **Option B - Lesser tuberosity osteotomy**: - Osteotomize lesser tuberosity with thin collar of bone (5mm) - Tag with two #2 FiberWire sutures through bone - Preserves tendon insertion, better healing potential - Risk: fracture, nonunion of osteotomy **Critical step - "Three Sisters"**: - Identify anterior circumflex humeral vessels at inferior border of subscapularis - Ligate or cauterize BEFORE completing subscapularis release - Prevents obscuring bleeding **Exam Answer**: "For fracture cases, the subscapularis is often torn with the lesser tuberosity fragment - I identify and tag it with strong sutures. For elective cases, I perform either subscapularis tenotomy 1cm from insertion or lesser tuberosity osteotomy with a thin collar of bone - both tagged with #2 FiberWire. I ligate the three sisters - the anterior circumflex vessels at the inferior subscapularis border." - Subscapularis repair failure = anterior instability (main cause of dislocation) - Three sisters bleeding = obscured field (ligate FIRST) - Axillary nerve lies just below inferior subscapularis border - Excessive release = external rotation contracture risk - Inadequate release = difficulty exposing joint --- ### Step 4: Capsular Release and Joint Exposure **Technique**: - Release anterior capsule from glenoid rim - Place stay sutures in capsule for later repair - Release superiorly in rotator interval (to supraspinatus) - Release inferiorly (GENTLY - axillary nerve) - Apply gentle external rotation, extension, adduction to deliver head **For TRAUMA cases**: - Assess fracture pattern (identify head, shaft, GT, LT fragments) - Assess head viability - look for soft tissue attachments (if none = AVN risk) - Document fracture configuration **For ELECTIVE cases**: - Assess humeral head articular cartilage - Assess glenoid cartilage quality - Confirm diagnosis (OA vs AVN vs other) **Exam Answer**: "I release the anterior capsule from the glenoid and place stay sutures. I release the rotator interval superiorly and gently release inferiorly - protecting the axillary nerve which is 5-7cm below the acromion. I deliver the head with external rotation, extension, and adduction. For fractures, I identify all four fragments and assess head viability." - Iatrogenic humeral shaft fracture - especially in osteoporotic bone, gentle manipulation - Axillary nerve injury - inferior capsular release most dangerous - Rotator cuff tear - aggressive manipulation can extend fracture lines - Glenoid fracture - from retractor or excessive force --- ### Step 5: Humeral Head Resection and Canal Preparation **For TRAUMA**: - Remove comminuted head fragments - Save greater and lesser tuberosity fragments (preserve soft tissue) - Clear canal of debris and blood clot **For ELECTIVE**: - Osteotomy at anatomic neck (resection guide typically used) - Remove at 130-135° to shaft axis, 30-40° retroversion - Measure resected head for sizing **Canal preparation**: - Insert canal finder/reamer - Sequential reaming (start small, increase size) - Ream until cortical chatter (avoid over-reaming) - Sequential broaching - Broach until cortical contact (avoid over-sizing) **Critical assessments with trial stem**: 1. **HEIGHT**: Restore normal offset (compare to native or opposite shoulder) 2. **VERSION**: 30-40° retroversion to epicondylar axis (palpate epicondyles with elbow flexed) 3. **SIZE**: Cortical contact without over-sizing (fracture risk in osteoporotic bone) **Exam Answer**: "I remove the damaged head, preserving tuberosity fragments with soft tissue in fracture cases. I ream and broach the canal sequentially, avoiding over-sizing which risks fracture in osteoporotic bone. With the trial stem I assess three critical parameters: HEIGHT to restore offset, VERSION 30-40° retroversion to the epicondyles, and SIZE for cortical contact without fracture risk." - IATROGENIC SHAFT FRACTURE - most common with over-sizing broach/stem in osteoporotic bone - Malversion - difficult to correct after cementing (check version repeatedly) - Incorrect height - overstuffing causes stiffness, understuffing causes instability - Humeral perforation - anterior cortex at risk with eccentric reaming --- ### Step 6: Trialing and Soft Tissue Balancing **Head sizing**: - Match native head diameter (measure resected head or templating) - Typical range 42-50mm diameter - Various eccentricities available (standard vs offset) **Trialing sequence**: 1. Insert trial stem at correct height, version, size 2. Attach trial humeral head 3. Reduce glenohumeral joint 4. Assess STABILITY: - Inferior translation with axial traction - Anterior-posterior translation - Should be stable, not excessive laxity 5. Assess ROM: - Passive forward elevation (goal 90-120° at this stage) - External rotation (30-40°) - Internal rotation 6. Assess TENSION: - Should feel "snug" but not overstuffed - Too tight = stiffness, glenoid wear - Too loose = instability, poor function **Adjustments**: - Change head size if too tight/loose - Change head eccentricity if needed - Adjust stem height (up/down) - Confirm version again **Exam Answer**: "I select a head size matching the native anatomy - typically 42-50mm. With trials reduced I perform three assessments: STABILITY with translation testing in all directions, ROM checking passive elevation and rotation, and TENSION - should feel snug but not overstuffed. Overstuffing causes stiffness and glenoid erosion, understuffing causes instability." - Overstuffing (head too large/tall) = stiffness, increased glenoid contact stress → erosion - Understuffing (head too small/short) = instability, poor rotator cuff function - Missing instability at this stage = postoperative dislocation - Eccentric head malposition affects center of rotation --- ### Step 7: Final Component Implantation **Cemented vs uncemented decision**: - **TRAUMA/osteoporotic**: Usually cemented (poor bone quality, immediate fixation) - **ELECTIVE/good bone**: Press-fit often suitable (bone preservation, biologic fixation) **Cementing technique** (if used): 1. Place cement restrictor 2cm beyond stem tip 2. Clean and dry canal 3. Mix cement (low viscosity for mantle penetration vs high viscosity for pressurization - system dependent) 4. Retrograde fill canal with cement gun 5. Pressurize cement with distal plug or finger 6. Insert stem at correct version and depth 7. Hold version stable until cement hardens (8-10 minutes) 8. Remove excess cement **Press-fit technique** (if used): 1. Clean canal 2. Insert stem with gradual impaction 3. Achieve metaphyseal fill and stability 4. Confirm version and depth **Final head attachment**: - Attach modular humeral head to Morse taper - Impact firmly - Check head seating and rotation **Exam Answer**: "I use cement for osteoporotic trauma cases and press-fit for good bone in elective cases. For cementing, I place a restrictor, clean the canal, and retrograde fill with cement. I insert the stem at 30-40° retroversion - this is critical as version cannot change after cement hardens. I attach the modular head and confirm seating." - MALVERSION on final component - cannot correct after cement hardens (disaster) - Cement extrusion into joint = third body wear - Air in cement = weak fixation, fracture risk - Stem prominent/recessed = offset wrong, affects function - Cement burns to soft tissue --- ### Step 8: Tuberosity Repair (Trauma) / Soft Tissue Balancing (Elective) **For TRAUMA - Tuberosity repair** (CRITICAL for outcome): **Principles**: - Anatomic reduction of greater and lesser tuberosities - Restore normal anatomy and rotator cable - Multiplanar fixation - Tuberosities 5-10mm below head level **Technique**: 1. Reduce greater tuberosity anatomically (lateral and posterior) 2. Reduce lesser tuberosity anatomically (anterior and medial) 3. **GT-to-GT sutures**: #5 Ethibond, horizontal mattress, restores rotator cable 4. **Vertical cerclage**: GT and LT to shaft, proximal to prosthesis, #5 Ethibond or wire 5. **Tuberosity-to-prosthesis**: Sutures through prosthesis fins/holes to tuberosities 6. Confirm tuberosities 5-10mm below head articular surface 7. Check ROM - tuberosities should not displace **For ELECTIVE**: - Check rotator cuff integrity - Assess balance with trials - Repair any iatrogenic cuff injury **Exam Answer**: "For fractures, tuberosity repair is THE critical determinant of functional outcome. I reduce the GT and LT anatomically around the prosthesis. I use three fixation planes: GT-to-GT with #5 Ethibond restores the rotator cable, vertical cerclage from tuberosities to shaft, and sutures from tuberosities to the prosthesis fins. Goal is tuberosities 5-10mm below the head level. I check ROM to confirm no displacement." - Tuberosity malunion/nonunion/resorption = POOR FUNCTION (most common cause of failure in fracture hemiarthroplasty) - Superior migration GT = subacromial impingement, cuff dysfunction - Inadequate fixation = early displacement - Sutures cut through osteoporotic bone - use large bites, consider plate augmentation - Overtensioning = fracture --- ### Step 9: Subscapularis Repair **Technique for tenotomy**: - Mobilize subscapularis (should reach lesser tuberosity without tension) - Drill 3-4 holes in lesser tuberosity (transosseous tunnels) - Pass #2 FiberWire sutures through bone tunnels - Pass sutures through subscapularis tendon (mattress configuration) - Tie with arm in neutral to 20° internal rotation - Test repair strength manually **Technique for LT osteotomy**: - Reduce LT fragment anatomically - Secure with screws (if fragment large enough) or heavy sutures - Ensure stable fixation **Critical assessment**: - Subscapularis should be snug but not over-tight - Test with passive external rotation - should achieve 30-40° - Too tight = rupture, external rotation loss - Too loose = anterior instability **Exam Answer**: "Subscapularis repair is critical for anterior stability. I use transosseous sutures through drill holes in the lesser tuberosity with #2 FiberWire in mattress configuration. I tie with the arm in neutral to slight internal rotation. The repair should be snug but allow 30-40° external rotation. Too tight risks rupture, too loose risks anterior instability." - Subscapularis failure = anterior instability, dislocation (main cause of instability) - Repair too tight = rupture, external rotation loss - Repair too loose = anterior subluxation/dislocation - Sutures pull through if bone quality poor --- ### Step 10: Capsular Repair and Closure **Capsule**: - Repair anterior capsule using stay sutures placed earlier - Absorbable sutures (0 or 2-0 Vicryl) - Snug but not over-tight **Final ROM assessment**: - Passive forward elevation (goal 90-120° immediate post-op) - External rotation (30-40°) - Internal rotation - Check stability - no subluxation with translation **Irrigation and hemostasis**: - Copious irrigation with 6-9 liters normal saline - Achieve meticulous hemostasis - Anterior circumflex should already be controlled - Cauterize any venous ooze **Deltopectoral interval**: - Close loosely or leave open (allows drainage, prevents hematoma) - If closing, use interrupted absorbable sutures **Subcutaneous and skin**: - Subcutaneous 2-0 Vicryl - Skin: staples or subcuticular suture **Immobilization**: - Shoulder immobilizer with arm in INTERNAL ROTATION (protects subscapularis repair) - Abduction pillow if used (some surgeons prefer for tuberosity healing) **Exam Answer**: "I repair the capsule, then perform final ROM and stability checks - passive elevation 90-120°, ER 30-40°, and confirm no subluxation. I irrigate copiously with 6-9 liters. I close the deltopectoral interval loosely to allow drainage and prevent hematoma. I apply a sling in INTERNAL ROTATION - this protects the subscapularis and tuberosity repairs for 4-6 weeks." - Hematoma if inadequate hemostasis = infection risk, stiffness - Arm positioned in external rotation = subscapularis repair rupture - Missing instability at closure = postoperative dislocation - Wound closure under tension = dehiscence risk elevation > IR). Distinguish true stiffness from rotator cuff dysfunction (passive ROM limited vs active limited).", "Prevention": "Avoid overstuffing (correct head size/height). Early ROM protocol - pendulums day 1, passive ROM weeks 0-6. Adequate pain control for rehab participation. Avoid subscapularis over-tightening.", "Management": "Aggressive physical therapy - passive stretching, capsular stretching. Consider manipulation under anesthesia if < 6 months from surgery. Arthroscopic or open capsular release if > 6 months and failed conservative treatment. Address underlying cause (overstuffing may require revision)." }, { "Complication": "Glenoid Erosion (Long-term problem - up to 50% by 5-10 years)", "Recognition": "Progressive pain (anterior and superior glenoid). Radiographs: glenoid wear, subchondral sclerosis, cysts. CT: quantify bone loss. MRI: assess rotator cuff integrity (determines revision options).", "Prevention": "Appropriate patient selection (young active patients better with TSA or reverse). Anatomic component positioning (avoid overstuffing, correct version). Balanced soft tissues. Counsel patients on realistic expectations and activity modification.", "Management": "Non-operative: activity modification, NSAIDs, injections if mild and tolerable. Operative (if symptomatic): Conversion to anatomic TSA if cuff intact and adequate glenoid bone stock, OR conversion to reverse TSA if cuff deficient or inadequate bone (more common). Revision technically demanding - bone grafting may be needed." }, { "Complication": "Periprosthetic Fracture (Intraoperative or late trauma)", "Recognition": "Intraoperative: sudden loss of stability, visible crack, palpable step-off. Post-operative: pain after fall/trauma, inability to use arm. Radiographs confirm fracture location and pattern (Vancouver classification adapted to shoulder).", "Prevention": "Avoid over-sizing stem (gentle broaching, sequential sizing). Gentle technique in osteoporotic bone. Cement technique if poor bone. Avoid excessive torque during insertion. Patient education about fall prevention.", "Management": "Intraoperative: Cerclage wires/cables proximal to stem, consider long stem, cement for immediate stability, protect post-op. Post-operative: Assess stem stability. If stem stable: ORIF with plates/cables. If stem loose: revision to longer stem with fracture fixation. If chronic with bone loss: consider allograft, reverse TSA." }, { "Complication": "Infection (1-2% incidence)", "Recognition": "Acute: fever, wound drainage, erythema, pain, elevated WBC/CRP/ESR. Chronic: persistent pain, stiffness, wound issues, elevated ESR/CRP. Aspiration: positive culture, WBC >3000, PMN >80%.", "Prevention": "Prophylactic IV antibiotics (cefazolin within 60 min). Sterile technique. Limit OR traffic. Meticulous hemostasis. Wound care. Optimize patient factors (diabetes control, nutrition, smoking cessation).", "Management": "Acute (<4 weeks): Irrigation and debridement, component retention (if stable), long-term suppressive antibiotics. Chronic: Two-stage revision - resection arthroplasty with antibiotic spacer (6-12 weeks IV antibiotics), then reimplantation. Consider reverse TSA at reimplantation (more forgiving soft tissues)." }, { "Complication": "Nerve Injury - Axillary nerve most common (5-8% incidence, especially in fracture cases)", "Recognition": "Axillary: deltoid paralysis (cannot abduct), sensory loss lateral arm. Musculocutaneous: weak elbow flexion, sensory loss lateral forearm. EMG/NCS at 3-4 weeks to confirm diagnosis and assess severity.", "Prevention": "Protect axillary nerve - avoid inferior dissection >5cm below acromion, gentle inferior retractor. Protect musculocutaneous - avoid aggressive medial retraction of conjoint. Atraumatic technique. Identify before injury if possible.", "Management": "Most are neurapraxias - observe for 3-6 months (up to 12-18 months for recovery). Physical therapy to prevent contractures. Tendon transfers if no recovery by 12-18 months (axillary: trapezius transfer for abduction). Neurolysis if nerve identified to be compressed at time of surgery." } ]} /> ## Additional Complications ### Heterotopic Ossification - **Incidence**: 20-40% radiographic, <5% clinically significant - **Risk factors**: Trauma, male gender, DISH, prior HO - **Prevention**: Indomethacin 25mg TID x 6 weeks (if no contraindication), or radiation (single dose 700 cGy within 72 hours) - **Management**: Observation if mild, excision if severe and mature (>12-18 months) with prophylaxis ### Component Loosening - **Incidence**: Rare with modern implants (<5% at 10 years) - **Recognition**: Pain with activity, radiographic lucency >2mm progressive - **Management**: Revision arthroplasty (anatomic or reverse TSA depending on cuff status) ### Rotator Cuff Failure (Elective cases) - **Recognition**: Weakness, limited active ROM (passive preserved), positive lag signs - **Management**: Physical therapy for compensation, consider revision to reverse TSA if symptomatic and cuff irreparable ## Post-operative Rehabilitation Protocol ### Phase 1: Protection Phase (Weeks 0-6) **Immobilization**: - Shoulder immobilizer with arm in internal rotation - Remove only for exercises and hygiene - **CRITICAL for fracture cases**: Tuberosity healing requires 6-12 weeks protection **Exercises**: - Pendulum exercises (Codman's) - start day 1-2 - **PASSIVE ROM only** - therapist or opposite arm - Forward elevation to 90° (week 0-4), then 120° (week 4-6) - External rotation to 20-30° (arm at side) - Internal rotation (hand to abdomen) - Elbow/wrist/hand active ROM to prevent stiffness - Scapular mobilization (gentle) **Restrictions**: - **NO active shoulder motion** (protects subscapularis and tuberosity repairs) - **NO lifting** with operative arm - **NO reaching behind back** **Goals**: Protect healing soft tissues, prevent stiffness, maintain distal ROM --- ### Phase 2: Early Active Motion (Weeks 6-12) **Progression criteria**: - Clinical healing of subscapularis (6 weeks minimum) - Radiographic tuberosity healing in fracture cases (6-12 weeks) - Pain controlled **Exercises**: - Continue passive ROM (progress to full) - **Active-assisted ROM** (weeks 6-8): - Supine forward elevation with stick/towel - External rotation with stick - Pulley exercises - **Active ROM** (weeks 8-12): - Elevation in scapular plane - External rotation - Internal rotation - Isometric strengthening (weeks 10-12): - Submaximal, pain-free - All planes **Restrictions**: - **NO resisted strengthening** until week 12 - Avoid sudden movements - Limit overhead activities **Goals**: Restore active ROM, begin muscle activation, transition to strengthening --- ### Phase 3: Strengthening (Weeks 12-24) **Exercises**: - Progressive resistive exercises: - Theraband (light → medium resistance) - Light weights (1-2 lbs → 5 lbs) - Rotator cuff strengthening (all planes) - Scapular stabilizers (rows, protraction, retraction) - Functional activities training - Proprioception exercises **Restrictions**: - Avoid heavy lifting (>10-15 lbs) until 6 months - Gradual return to activities **Goals**: Restore strength, improve function, return to ADLs --- ### Phase 4: Return to Function (6-12 months) **Activities**: - Unrestricted activities of daily living - Return to recreational activities (gradual) - Sport-specific training if applicable (low-demand sports only) **Restrictions**: - Permanent restrictions for heavy labor, high-demand sports - Counsel patients: hemiarthroplasty NOT designed for high-impact activities **Goals**: Maximize function within limitations, prevent complications --- ## Expected Outcomes ### Functional Outcomes **Pain relief**: Excellent (80-90% good/excellent pain relief) **ROM** (varies by indication): - **Trauma cases**: Lower expectations - Forward elevation: 90-120° (depends on tuberosity healing) - External rotation: 20-40° - Function often limited by cuff dysfunction - **Elective cases**: Better ROM - Forward elevation: 120-150° - External rotation: 40-60° - Better functional outcomes if cuff intact **Strength**: Generally weak compared to anatomic or reverse TSA (especially in trauma) **Satisfaction**: Variable - Higher in elective cases (OA, AVN) - Lower in trauma cases (tuberosity healing dependent) ### Comparison to Alternatives **Hemiarthroplasty vs Anatomic TSA**: - TSA superior for elective OA (better pain relief, ROM, function, satisfaction) - Hemi used when glenoid component not feasible (bone loss, young patient) **Hemiarthroplasty vs Reverse TSA** (for fracture): - **Reverse TSA** now preferred in elderly fracture patients: - Better functional outcomes (meta-analyses) - Not dependent on tuberosity healing - Lower revision rate - Higher complication rate (dislocation, infection) - **Hemiarthroplasty** role declining but still considered: - Younger patients (<65-70) with good bone quality - Concern for glenoid bone stock for reverse baseplate - Patient/surgeon preference ### Survivorship - **Implant survival**: 85-90% at 10 years - **Revision rate**: 10-15% at 10 years - Trauma cases higher (tuberosity failure, conversion to reverse) - Elective cases moderate (glenoid erosion, conversion to TSA/reverse) ### Prognostic Factors **Better outcomes**: - Elective indication (vs trauma) - Younger age (<70) - Intact rotator cuff - Anatomic tuberosity healing (fracture cases) - Good bone quality - Compliant with rehabilitation **Worse outcomes**: - Trauma indication - Tuberosity malunion/nonunion - Rotator cuff tear - Obesity - Diabetes - Smoking - Low patient expectations ## References 1. **Boileau P, Trojani C, Walch G, et al.** Shoulder arthroplasty for the treatment of the sequelae of fractures of the proximal humerus. *J Shoulder Elbow Surg*. 2001;10(4):299-308. doi:10.1067/mse.2001.115985 - Classic study on hemiarthroplasty for proximal humerus fracture sequelae, emphasizing importance of tuberosity healing for functional outcomes 2. **Mata-Fink A, Meinke M, Jones C, et al.** Reverse shoulder arthroplasty for treatment of proximal humeral fractures in older adults: a systematic review. *J Shoulder Elbow Surg*. 2013;22(12):1737-1748. doi:10.1016/j.jse.2013.08.021 - Systematic review demonstrating superior outcomes of reverse TSA compared to hemiarthroplasty for proximal humerus fractures in elderly patients 3. **Namdari S, Horneff JG, Baldwin K.** Comparison of hemiarthroplasty and reverse arthroplasty for treatment of proximal humeral fractures: a systematic review. *J Bone Joint Surg Am*. 2013;95(18):1701-1708. doi:10.2106/JBJS.L.01115 - Meta-analysis showing reverse TSA superior to hemiarthroplasty for acute fractures - better function, lower revision rate 4. **Petersen SA, Hawkins RJ.** Revision of failed shoulder arthroplasty for glenohumeral arthritis. *Orthop Clin North Am*. 1998;29(3):519-533. doi:10.1016/s0030-5898(05)70329-6 - Comprehensive review of revision shoulder arthroplasty, including management of glenoid erosion after hemiarthroplasty 5. **Rispoli DM, Sperling JW, Athwal GS, et al.** Humeral head replacement for the treatment of osteoarthritis. *J Bone Joint Surg Am*. 2006;88(12):2637-2644. doi:10.2106/JBJS.F.00449 - Long-term outcomes of hemiarthroplasty for primary OA, demonstrating high rate of glenoid erosion and need for revision 6. **Norris TR, Green A, McGuigan FX.** Late prosthetic shoulder arthroplasty for displaced proximal humerus fractures. *J Shoulder Elbow Surg*. 1995;4(4):271-280. doi:10.1016/s1058-2746(05)80021-4 - Classic paper on tuberosity management in fracture hemiarthroplasty, establishing principles of anatomic reduction and secure fixation 7. **Boileau P, Winter M, Cikes A, et al.** Can surgeons predict what makes a good hemiarthroplasty for fracture? *J Shoulder Elbow Surg*. 2013;22(11):1495-1506. doi:10.1016/j.jse.2013.04.018 - Study identifying predictors of good outcomes after fracture hemiarthroplasty, emphasizing tuberosity healing and patient factors 8. **Kralinger F, Schwaiger R, Wambacher M, et al.** Outcome after primary hemiarthroplasty for fracture of the head of the humerus. *J Bone Joint Surg Br*. 2004;86(2):217-219. doi:10.1302/0301-620x.86b2.14553 - Long-term outcomes study showing inferior results of hemiarthroplasty for fractures compared to elective indications 9. **Rasmussen JV, Hole R, Metlie T, et al.** Anatomical total shoulder arthroplasty used for glenohumeral osteoarthritis has higher survival rates than hemiarthroplasty: a Nordic registry-based study. *Clin Orthop Relat Res*. 2018;476(9):1748-1755. doi:10.1007/s11999.0000000000000139 - Nordic registry data demonstrating superior survivorship of anatomic TSA compared to hemiarthroplasty for primary OA 10. **Levy JC, Badman B.** Reverse shoulder prosthesis for acute four-part fracture: tuberosity fixation using a horseshoe graft. *J Orthop Trauma*. 2011;25(5):318-324. doi:10.1097/BOT.0b013e3181f22088 - Technical article on reverse TSA for acute fractures with tuberosity fixation technique, representing modern approach to complex fractures

Shoulder Hemiarthroplasty - Deltopectoral Approach

Shoulder Hemiarthroplasty - Deltopectoral Approach