Shoulder Hemiarthroplasty

The Neer pattern, the patient's age and the state of the cuff guide the surgical decision.

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Avascular necrosis is the best non-fracture indication. The ideal case is Ficat stage III-IV necrosis with intact glenoid cartilage, in a young patient who wants to preserve glenoid bone stock. Resurfacing arthroplasty is the alternative if enough head remains.

Osteoarthritis gives hemiarthroplasty a limited role: if the glenoid is arthritic, TSA is preferred. The exception is the young, high-demand patient, in whom ream-and-run resurfaces the glenoid biologically and preserves its bone stock for a future TSA. It requires an intact rotator cuff. At 10 years, 75% have good or excellent results, but 25% progress to glenoid arthritis requiring conversion to TSA.

Absolute contraindications

• Active infection: septic arthritis or osteomyelitis
• Deltoid paralysis: inadequate power for elevation
• Severe glenoid bone loss with instability
• Neuropathic arthropathy (Charcot shoulder)

Relative contraindications

• Advanced glenoid arthritis: TSA preferred
• Rotator cuff arthropathy: reverse TSA better
• Poor bone quality: consider cemented fixation
• Low-demand elderly patient with a fracture: reverse TSA superior
• Medical comorbidities: optimise, or consider non-operative care

Select the patient. Age, cuff status, medical fitness and expectations come first. A young patient (under 65) with an intact cuff is a hemiarthroplasty candidate; in the elderly (over 70), or with cuff dysfunction, reverse TSA is preferred; the medically unfit are managed conservatively.

Confirm the pattern. The CT with 3D reconstruction confirms a 3- or 4-part pattern, a head split or severe impaction, the size and displacement of the tuberosity fragments, and glenoid integrity.

Plan the operation. If hemiarthroplasty is chosen, template the stem and head, plan tuberosity fixation with sutures through the stem, make sure heavy Number 5 non-absorbable sutures are available, and decide cemented or uncemented on bone quality.

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The glenoid and the cuff decide. Glenoid cartilage status determines the treatment, and cuff integrity determines the implant type. On MRI, a Goutallier grade over 2 (over 50% fatty infiltration) points to reverse.

Then the patient. Activity level and goals tip the balance. The young, high-demand patient has the glenoid preserved with a hemiarthroplasty, the elderly, low-demand patient is given a TSA for better pain relief, and poor bone quality calls for cemented fixation.

Position. Beach chair on a specialised shoulder table, body 60-80° upright, head secured in neutral with slight extension. The affected arm is left free to move across the body, with adequate posterior access for the axillary view.

Padding protects the nerves at risk:

• Brachial plexus: avoid head tilt away from the surgical side
• Ulnar nerve: pad the elbow if an arm board is used
• Peroneal nerve: pad at the fibular head
• Sacrum: padded to prevent a pressure sore

Draping leaves exposed the sternoclavicular joint medially, the AC joint and acromion superiorly, the anterior and posterior shoulder, and the proximal humerus to mid-shaft. Ensure C-arm access for AP and axillary views.

The deltopectoral approach is the standard for hemiarthroplasty.

1. Incision. From the coracoid tip, 8-10cm distally, directly over the deltopectoral groove; palpate the cephalic vein to find the interval. It can be extended proximally over the clavicle if needed.
2. Superficial interval. Develop the interval between deltoid (lateral) and pectoralis major (medial), ligating small crossing vessels. The cephalic vein usually lies laterally with the deltoid.
3. Deep dissection. Divide the clavipectoral fascia lateral to the conjoined tendon, palpate the coracoid tip (the conjoined tendon origin), and identify the rotator interval between supraspinatus and subscapularis.
4. Subscapularis. Either a tenotomy, releasing the tendon 1cm medial to its insertion on the lesser tuberosity and tagging it with heavy suture for later repair to bone, or, in fracture hemiarthroplasty, a lesser tuberosity osteotomy with a 5mm bone wafer, which gives better bone-to-bone healing and is repaired with sutures through holes in the tuberosity.
5. Joint exposure. Incise the capsule along the subscapularis tendon, release it from the glenoid anteriorly and inferiorly, and deliver the head with external rotation and extension. In a fracture, mobilise the tuberosity fragments carefully.

1. Identify and tag every fragment with heavy suture immediately: the greater tuberosity (supraspinatus, infraspinatus, teres minor), the lesser tuberosity (subscapularis), the head (removed for hemiarthroplasty) and the shaft.
2. Preserve soft-tissue attachments. Keep the rotator cuff attached to the tuberosities, clear only minimal soft tissue from the fracture edges, and preserve the periosteum on the shaft. Do NOT strip the tuberosity fragments: their blood supply is critical.
3. Remove the head with an osteotomy at the anatomic neck. Measure its size (use it as the template) and its version relative to the epicondyles, and note the head height above the greater tuberosity.
4. Prepare the canal in the shaft fragment. Ream gently in osteoporotic bone, size the stem slightly under if it is to be cemented, and preserve the medial calcar if possible.
5. Cement the stem, the preferred technique for fracture because it gives immediate stability for tuberosity healing. Clean and dry the canal, place a distal cement restrictor, and use low-viscosity cement with a cement gun. Insert the stem at the target retroversion (referenced to the epicondyles), with its height set against the planned greater tuberosity position, and remove excess cement before it has fully set.

Tuberosity reconstruction is critical for outcome.

1. Place the sutures before reduction. Number 5 non-absorbable (Ethibond or FiberWire) through the tendon-bone junction of each tuberosity, 3-4 per tuberosity, in a horizontal mattress pattern through the cuff.
2. Position the greater tuberosity anatomically: 5-8mm below the top of the stem, not level with it; lateral and posterior to the bicipital groove (slight retroversion); flush with the shaft laterally, with no step-off.
3. Position the lesser tuberosity medial to the bicipital groove, recreating the groove between the two tuberosities and restoring subscapularis tension, without impingement on the coracoid in internal rotation.
4. Fix with a figure-of-8 from greater to lesser tuberosity, through the holes in the stem or, if it has none, around its neck. Add vertical mattress sutures from the tuberosities to the shaft below. Tension the sutures with the arm in neutral rotation.
5. Check the construct. The tuberosities should be stable with arm rotation, with no gapping between fragments, the bicipital groove recreated and full range without tuberosity impingement. Confirm version and height on the C-arm.

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1. Head osteotomy at the anatomic neck, just above the greater tuberosity, using the template or the contralateral measurement. Preserve the greater and lesser tuberosity attachments and note the native version and height.
2. Canal preparation. Identify the canal in the centre of the metaphysis and ream sequentially to the planned size. The goal is metaphyseal fill for a press-fit (uncemented) stem, or slight undersizing if cement is planned; preserve the medial calcar for medial offset.
3. Version and height. Establish the epicondylar axis with a gauge, or by palpating the epicondyles with the elbow at 90°, and use the bicipital groove as a check. Measure the height with the trials.
4. Trial reduction. With the trial stem and head in place, check version with arm rotation, stability (no subluxation) and full passive range without impingement. The correct head size gives slight tension without overstuffing.
5. Final implant. Press-fit the stem and insert the head, or cement as for fracture; reduce, and repeat the range and stability check.

1. Subscapularis repair. After a tenotomy, heavy sutures through holes in the lesser tuberosity; after a lesser tuberosity osteotomy, sutures to the shaft and greater tuberosity. Tension with the arm in neutral rotation. The repair is critical for anterior stability.
2. Rotator interval. It may be left open for range if the shoulder is stable; close it if there is an instability concern or a tendency to posterior subluxation.
3. Superficial closure. Do NOT close the deltopectoral fascia, which causes stiffness. Close the subcutaneous layer with absorbable suture, and the skin subcuticular or with staples.
4. Immobilisation. A shoulder immobiliser or simple sling, in neutral rotation with a slight abduction pillow: 4-6 weeks after fracture; after a non-fracture operation it comes off for pendulums on day 1.

After fracture hemiarthroplasty, rehabilitation is built around tuberosity healing. The tuberosities need 6-8 weeks of protection before active movement.

Weeks 0-6: protection. The sling is worn continuously. Motion is passive only (pendulums, table slides, pulley-assisted), with no active muscle contraction, while elbow, wrist and hand exercises prevent stiffness. Opioids are used in week 1, then non-opioids; DVT prophylaxis is aspirin 325mg or LMWH (high risk).

Weeks 6-12: active-assisted, if the tuberosities are healing. A radiograph at 6 weeks assesses tuberosity position and healing. Active-assisted range follows with gentle pulleys and wand exercises, submaximal isometric strengthening in neutral, and continued passive range to hold the gains. The sling is weaned during the day and kept at night.

Weeks 12-16: strengthening. Active range in all planes, theraband resistance for external and internal rotation and elevation, and scapular stabilisation exercises, progressing gradually to functional activities. The sling is discontinued.

Months 4-12: functional recovery. Strengthening continues to a plateau, typically at 9-12 months, with goals set by daily living and work tasks. Overhead impact activities are avoided (tuberosity stress), and an annual radiograph monitors glenoid erosion and tuberosity position.

With no tuberosity to protect, AVN and OA allow immediate aggressive passive range from day 1. The goal is to prevent capsular contracture and stiffness.

Day 1. The sling comes off for exercises: pendulums, table slides for forward elevation, and passive external and internal rotation.

Weeks 2-6: range. Aggressive passive range with physiotherapy 2-3 times a week, aiming for passive elevation to 140°, external rotation in scaption to 45° and internal rotation to T12. No strengthening yet, as the subscapularis is healing if a tenotomy was done.

Weeks 6-12: strengthening. Active range in all planes, theraband resistance progressing to light weights, and functional training for daily living.

Months 3-6: full function. Unrestricted range and strength training. Return to sedentary work at 6 weeks and to manual work at 3-4 months; avoid overhead impact sports (glenoid erosion risk).

Global Epidemiology

Proximal humeral fractures are among the most common osteoporotic fractures, rising steeply with age and female sex, and most occur in patients over 60 from a low-energy fall. Across high-income healthcare systems the majority are managed non-operatively, with only a minority (broadly in the order of 15-30% in published series) treated surgically; arthroplasty is reserved for complex three- and four-part and head-splitting patterns where reconstruction or fixation is unreliable.

Major Guidelines Side by Side

Registry Evidence

Global Practice Variation

Implant choice is strongly resource- and cost-dependent. In well-resourced systems reverse arthroplasty has largely displaced hemiarthroplasty for elderly fracture; in lower-resource settings hemiarthroplasty (or non-operative management and locking-plate fixation) remains more common because reverse implants are costlier and require revision-capable infrastructure. For younger patients with reconstructable anatomy and an intact cuff, hemiarthroplasty and ream-and-run retain a defined role worldwide because they preserve glenoid bone stock.

Medicolegal and Consent Considerations

Failure to offer reverse arthroplasty: in elderly patients with complex fractures, not discussing reverse arthroplasty as an alternative may be considered substandard given current evidence - document the discussion.

Hemiarthroplasty for an arthritic glenoid: performing hemiarthroplasty alone for osteoarthritis with established glenoid wear gives inferior function to total shoulder arthroplasty and is a recognised source of dissatisfaction and litigation.