SHOULDER HEMIARTHROPLASTY
Proximal Humerus Fracture | Tuberosity Reconstruction | Alternative to TSA
PRIMARY INDICATIONS
Critical Must-Knows
- Tuberosity healing dictates outcome in fracture hemiarthroplasty - only 40-50% achieve anatomic healing
- Height and version: Stem proud 5-8mm above greater tuberosity, 20-30° retroversion critical for function
- Biological vs anatomic: Reverse shoulder has largely replaced hemiarthroplasty for elderly fracture patients
- Glenoid erosion: Occurs in 50% by 10 years - superior migration from rotator cuff dysfunction
- Australian context: AOANJRR shows hemiarthroplasty declining - reverse TSA preferred for fractures
Examiner's Pearls
- "HEALTH trial: Hemiarthroplasty inferior to TSA and reverse for displaced femoral neck fractures (shoulder equivalent)
- "Tuberosity fixation: Heavy non-absorbable sutures through bone-tendon interface, figure-of-8 pattern
- "Ream-and-run: Modern alternative preserving glenoid bone stock in young patients
- "Instability risk: Anterior instability if under 20° retroversion, posterior if over 40°
Clinical Imaging
Imaging Gallery
Critical Shoulder Hemiarthroplasty Exam Points
Tuberosity Healing is Key
Only 40-50% achieve anatomic healing. Non-union or malunion leads to poor elevation and external rotation. Requires 6-8 weeks protection before active movement.
Height and Version Targets
Stem proud 5-8mm above greater tuberosity. Retroversion 20-30° relative to epicondylar axis. Too proud = impingement; too low = cuff dysfunction.
Reverse Has Replaced Hemi for Fractures
Modern trend: Reverse shoulder arthroplasty superior outcomes for elderly proximal humerus fractures. Hemiarthroplasty reserved for young, high-demand patients with intact rotator cuff.
Glenoid Erosion Inevitable
50% by 10 years develop glenoid arthritis. Superior migration from rotator cuff insufficiency. Warn patients of potential conversion to TSA or reverse.
Quick Decision Guide - Hemiarthroplasty vs Alternatives
| Patient | Pathology | Treatment | Key Pearl |
|---|---|---|---|
| Young (under 65), active, intact cuff | 3-4 part fracture | Hemiarthroplasty + tuberosity repair | Best chance for tuberosity healing |
| Elderly (over 70), low demand | 3-4 part fracture | Reverse shoulder arthroplasty | Superior outcomes, tuberosity healing not critical |
| Young, high-demand | AVN without glenoid arthritis | Hemiarthroplasty (ream-and-run) | Preserves glenoid bone stock for future TSA |
| Elderly, painful OA | Glenoid arthritis present | Total shoulder arthroplasty | Hemiarthroplasty alone gives poor pain relief |
HEALSTuberosity Fixation Principles
Memory Hook:Tuberosity HEALS when fixation is solid - think figure-of-8 sutures creating a healing scaffold!
PROUDStem Version and Height Assessment
Memory Hook:Stem should be PROUD but not too proud - Goldilocks height 5-8mm above greater tuberosity!
PAINHemiarthroplasty Complications to Discuss
Memory Hook:PAIN is the main complication of hemiarthroplasty - especially from glenoid erosion!
Overview and Epidemiology
Clinical Context
Shoulder hemiarthroplasty involves replacement of the humeral head while preserving the native glenoid. Historically the gold standard for complex proximal humerus fractures in the elderly, its role has been largely supplanted by reverse shoulder arthroplasty which offers superior outcomes regardless of tuberosity healing.
Current indications are narrowing to:
- Young patients (under 65) with 3-4 part fractures and intact rotator cuff
- Avascular necrosis without glenoid arthritis
- Severe glenoid bone loss where component fixation is inadequate
- High-demand patients as biological resurfacing (ream-and-run)
Paradigm Shift in Fracture Management
The DELPHI trial (2019) demonstrated reverse shoulder arthroplasty superior outcomes compared to hemiarthroplasty for elderly displaced proximal humerus fractures. Tuberosity healing, previously critical, is no longer required for good function with reverse prosthesis. Hemiarthroplasty now reserved for young, high-demand patients with intact cuff where tuberosity healing is more likely.
Demographics
- Age: Bimodal - young trauma or elderly fracture
- Gender: F greater than M (3:1 for fractures)
- Bone quality: Critical for stem fixation
- Activity level: Determines implant selection
Functional Expectations
- Pain relief: Good to excellent in 80-85%
- Elevation: Average 100-120° (cuff-dependent)
- External rotation: Often limited (tuberosity healing)
- Revision rate: 15-20% by 10 years
Anatomy and Biomechanics
Proximal Humerus Surgical Anatomy
Critical Neurovascular Structures
Axillary nerve runs 5-7cm distal to acromion on anterior deltopectoral approach. Traction injuries occur with inferior retraction. Anterior humeral circumflex artery at inferior border of subscapularis - ligate carefully to avoid axillary nerve injury during mobilization.
| Structure | Clinical Significance | Surgical Relevance |
|---|---|---|
| Greater tuberosity | Supraspinatus, infraspinatus, teres minor insertion | Must sit 5-8mm below stem; controls elevation and ER |
| Lesser tuberosity | Subscapularis insertion | Medial to bicipital groove; controls IR and stability |
| Bicipital groove | Long head biceps anatomic landmark | Version reference - 30° posterior to groove = 30° retroversion |
| Axillary nerve | 5-7cm inferior to acromion anteriorly | At risk with inferior retractor placement and dissection |
Biomechanical Principles
Version: 20-30° retroversion relative to epicondylar axis. Less than 20° risks anterior instability; greater than 40° causes posterior instability and limits IR.
Height: Stem proud 5-8mm above greater tuberosity equates to anatomic head height. Too high causes impingement; too low reduces deltoid tension and cuff function.
Offset: Medial offset preserves deltoid tension. Excessive lateral offset overstuffs joint and limits ROM.
Classification and Indications
Proximal Humerus Fracture
Neer Classification guides surgical decision:
| Pattern | Age/Cuff Status | Treatment | Rationale |
|---|---|---|---|
| 3-part fracture | Young (under 65), intact cuff | Hemiarthroplasty + tuberosity repair | Potential for tuberosity healing and good function |
| 4-part fracture | Young (under 65), intact cuff | Hemiarthroplasty + tuberosity repair | Head AVN inevitable; preserve glenoid if possible |
| 4-part fracture | Elderly (over 70) | Reverse shoulder arthroplasty | Superior outcomes; tuberosity healing not critical |
| Head-splitting fracture | Any age, articular comminution | Hemiarthroplasty or reverse | Head reconstruction impossible |
Why Reverse Has Replaced Hemi
DELPHI trial: Reverse TSA superior to hemiarthroplasty for elderly 3-4 part fractures. At 2 years: Constant score 60 vs 48, complications 29% vs 43%. Reverse does not depend on tuberosity healing for function - deltoid provides power. Reserve hemiarthroplasty for young patients with intact cuff where anatomic reconstruction possible.
Fracture Imaging Examples
Clinical Assessment
History
- Mechanism: Fall onto shoulder (fracture) or chronic pain (arthritis/AVN)
- Pain: Night pain, rest pain, activity pain
- Function: What activities limited - dressing, reaching, lifting
- Prior surgery: Previous fixation attempts, infection
- Medical comorbidities: Diabetes (infection risk), smoking (healing)
- Expectations: Realistic about recovery and limitations
Examination
- Look: Swelling, bruising (fracture), deformity, muscle wasting
- Feel: Tenderness, crepitus, tuberosity prominence
- Move: Active and passive ROM in all planes
- Power: Rotator cuff testing - supraspinatus, infraspinatus, subscapularis
- Neurovascular: Axillary nerve (deltoid sensation), distal pulses
- Special tests: Cross-body adduction (AC joint), Neer/Hawkins (impingement)
Rotator Cuff Assessment Critical
| Test | Muscle Tested | Interpretation |
|---|---|---|
| Jobe test (empty can) | Supraspinatus | Weakness = poor outcome for hemiarthroplasty |
| External rotation resisted | Infraspinatus, teres minor | Essential for ER after tuberosity repair |
| Lift-off test, belly-press | Subscapularis | Critical for anterior stability |
| Lag signs (ER, IR) | Chronic massive tear | Consider reverse TSA instead of hemi |
Pseudo-Paralysis Indicates Cuff Arthropathy
Active elevation less than 90° with full passive ROM indicates massive rotator cuff tear or cuff arthropathy. This is a contraindication to hemiarthroplasty - patient requires reverse TSA. Hemiarthroplasty without functioning cuff leads to superior migration, glenoid erosion, and poor outcomes.
Investigations
Imaging Protocol
AP, scapular Y, axillary views:
- Fracture pattern (2-part vs 3-part vs 4-part)
- Head-shaft angle and impaction
- Glenoid morphology and version
- Greater tuberosity displacement and comminution
- Inferior subluxation (deltoid failure)
Essential for surgical planning:
- Fracture pattern and fragment size
- Head split or impaction
- Glenoid bone loss and version
- Canal size for stem templating
- Contralateral for version reference
Assess soft tissues:
- Rotator cuff integrity and quality
- Muscle atrophy (fatty infiltration Goutallier grade)
- Labral pathology
- AVN extent (edema pattern)
Preoperative Planning Essentials
Templating
- Head size: Measure contralateral or template best-fit
- Stem size: Canal fill at isthmus (metaphyseal stems)
- Offset: Match native anatomy (medial calcar restoration)
- Version: 20-30° retroversion target
- Height: 5-8mm stem proud of GT
Bone Stock Assessment
- Metaphyseal bone: Sufficient for press-fit vs cement needed
- Calcar integrity: Medial support for stem
- Tuberosity quality: Bone quality for suture fixation
- Glenoid wear: Eccentric vs concentric (consider TSA)
Management Algorithm
Acute Proximal Humerus Fracture Decision Tree
Treatment Algorithm
Age, cuff status, medical fitness, expectations
- Young (under 65) + intact cuff = hemiarthroplasty candidate
- Elderly (over 70) or cuff dysfunction = reverse TSA preferred
- Medical unfit = conservative management
CT scan with 3D reconstruction
- 3-part or 4-part fracture pattern
- Head split or severe impaction
- Tuberosity fragment size and displacement
- Glenoid integrity
If hemiarthroplasty chosen:
- Template stem size and head size
- Plan tuberosity fixation (sutures through stem)
- Ensure heavy sutures available (Number 5 non-absorbable)
- Cemented vs uncemented based on bone quality
Within 2-3 weeks of injury:
- Earlier surgery = easier soft tissue dissection
- Delayed beyond 3 weeks = tuberosity scarring and retraction
- Chronic (over 6 weeks) = consider reverse if tuberosities atrophic
Timing of Fracture Hemiarthroplasty
Operate within 2-3 weeks for best tuberosity healing potential. Earlier = easier dissection and reduction. Delayed beyond 3 weeks leads to soft tissue contracture, tuberosity retraction, and scarring. Beyond 6 weeks: consider reverse TSA as tuberosities may be atrophic and non-viable for reconstruction.
Surgical Technique
Pre-operative Planning
Consent Points
- Infection: 1-2% superficial, 0.5-1% deep
- Nerve injury: Axillary nerve (2-5%), musculocutaneous
- Instability: 2-5% (anterior if under 20° retroversion)
- Tuberosity non-union: 40-50% in fracture setting
- Glenoid erosion: 50% by 10 years (may need revision to TSA)
- Stiffness: Requires aggressive physiotherapy
- Need for revision: 15-20% by 10 years
Equipment Checklist
- Implants: Stemmed hemiarthroplasty system (cemented if fracture)
- Head sizes: 38-52mm range available
- Sutures: Heavy non-absorbable (Number 5 Ethibond or FiberWire) for tuberosities
- Cement: If osteoporotic bone or fracture
- Power: Drill for stem preparation, reamer for glenoid (ream-and-run)
- Imaging: C-arm for version and height assessment
Patient Positioning and Setup
Setup Checklist
Beach chair position on specialized shoulder table.
- Head: Secured in neutral, slight extension
- Body: 60-80° upright
- Affected arm: Free to move across body
- Ensure adequate posterior access for axillary view
Critical nerve protection:
- Brachial plexus: Avoid head tilt away from surgical side
- Ulnar nerve: Pad elbow if arm board used
- Peroneal nerve: Pad at fibular head
- Sacrum: Padded to prevent pressure sore
Landmarks exposed:
- Sternoclavicular joint medially
- AC joint and acromion superiorly
- Anterior and posterior shoulder
- Proximal humerus to mid-shaft
- C-arm access: Ensure can get AP, axillary views
Beach Chair vs Lateral Position
Beach chair preferred for shoulder arthroplasty (90% surgeons). Advantages: easier conversion to open deltopectoral, better C-arm access, less brachial plexus traction. Lateral position used by some for better posterior access and avoids hypotension issues but requires assistant to hold arm and more complex draping.
Technical Pearls and Pitfalls
Do's (Pearls)
- Cement in fractures: Immediate stability for tuberosity healing
- Version to epicondyles: 20-30° retroversion prevents instability
- Height 5-8mm proud: Goldilocks zone - not too high (impingement) or low (cuff dysfunction)
- Heavy sutures: Number 5 non-absorbable for tuberosity fixation
- Trial extensively: Check ROM, stability, impingement before final
- C-arm confirmation: Version and height intraoperatively
Don'ts (Pitfalls)
- Strip tuberosities: Preserve all soft tissue for blood supply
- Under 20° version: Causes anterior instability
- Over 40° version: Limits internal rotation, posterior instability
- Stem too proud: Impingement and pain
- Stem too low: Cuff dysfunction, superior migration
- Inferior retractor: Axillary nerve injury risk
Intraoperative Troubleshooting
Common Problems and Solutions
| Problem | Cause | Solution |
|---|---|---|
| Tuberosities will not reduce | Soft tissue contracture, incorrect height | Check stem height (may be too proud); mobilize soft tissues; use traction sutures |
| Anterior instability with trial | Version under 20° retroversion | Remove stem, cement in more retroversion (25-30°) |
| Posterior subluxation | Version over 40° retroversion, posterior cuff deficiency | Reduce retroversion; check posterior cuff intact; may need reverse if cuff deficient |
| Shaft fracture during reaming | Osteoporotic bone, eccentric reaming | Extend stem distally; cerclage cables; consider long-stem implant |
Complications
| Complication | Incidence | Risk Factors | Management |
|---|---|---|---|
| Tuberosity non-union or malunion | 40-50% in fractures | Osteoporosis, poor fixation, early motion | Observation if minimal symptoms; revision if painful with poor function |
| Glenoid erosion (arthritis) | 50% by 10 years | Cuff dysfunction, superior migration, high activity | Convert to TSA or reverse TSA if painful |
| Instability | 2-5% | Malversion (under 20° or over 40°), subscapularis failure | Anterior: Repair subscapularis, consider glenoid component. Posterior: Revision to correct version |
| Infection | 1-2% overall | Diabetes, smoking, prolonged surgery | Early (under 3 weeks): I&D, retain implant. Late: Explant, spacer, reimplant |
| Nerve injury (axillary) | 2-5% | Inferior retractor, traction, dissection | Usually neurapraxia - recovers 3-6 months. EMG at 6 weeks if no recovery |
| Periprosthetic fracture | 2-3% | Trauma, osteoporosis, uncemented stems | Above stem: ORIF. At stem: Revision to long stem. Below stem: ORIF with cables |
| Stiffness | 10-15% | Inadequate therapy, capsular contracture | Aggressive PT; manipulation under anesthesia if under 6 months; arthroscopic release if chronic |
Tuberosity Failure is the Achilles Heel
40-50% tuberosity non-union or malunion rate in fracture hemiarthroplasty. Results in poor elevation (supraspinatus detachment) and external rotation (infraspinatus). Prevention: Anatomic position, solid fixation with heavy sutures, protect 6 weeks. If occurs: Observation if asymptomatic. Revision if painful and functional limitation - very challenging surgery with poor outcomes. This is why reverse TSA has largely replaced hemiarthroplasty for elderly fractures.
Postoperative Care and Rehabilitation
Hemiarthroplasty for Fracture Rehabilitation
Fracture Rehabilitation Timeline
Goal: Tuberosity healing
- Immobilization in sling continuously
- Passive ROM only: Pendulums, table slides, pulley-assisted
- No active muscle contraction (protect tuberosity repair)
- Elbow, wrist, hand exercises to prevent stiffness
- Pain control: Opioids week 1, transition to non-opioids
- DVT prophylaxis: Aspirin 325mg or LMWH (high risk)
Progress if radiographic tuberosity healing:
- X-ray at 6 weeks: Assess tuberosity position and healing
- Active-assisted ROM: Gentle pulleys, wand exercises
- Isometric strengthening: Submaximal in neutral
- Continue passive ROM to maintain gains
- Wean sling during day, continue night use
Advance to resisted exercises:
- Active ROM all planes
- Theraband resistance: ER, IR, elevation
- Scapular stabilization exercises
- Gradual progression to functional activities
- Discontinue sling
Maximize function:
- Progressive strengthening to plateau
- Functional goals: ADLs, work tasks
- Plateau typically 9-12 months
- Avoid overhead impact activities (tuberosity stress)
- Annual X-ray: Monitor glenoid erosion, tuberosity position
No Active Motion First 6 Weeks
Critical: No active muscle contraction for 6 weeks post-op in fracture hemiarthroplasty. Passive ROM only to prevent tuberosity displacement. Patient education essential - instruct to let therapist or opposite arm move the shoulder. Early active motion is the most common cause of tuberosity failure.
Follow-up Schedule
| Timepoint | Assessment | Key Points |
|---|---|---|
| 2 weeks | Wound check, begin PT | Remove sutures/staples; confirm PT started; pain control adequate |
| 6 weeks | X-ray, advance therapy | Fracture: Tuberosity healing? If yes, start active-assisted. Non-fracture: Check component position, advance strengthening |
| 3 months | ROM and function assessment | Expected 100-120° elevation, 30-40° ER. If plateau, consider manipulation |
| 1 year | Outcome scores, imaging | ASES or Constant score. X-ray: Tuberosity position, glenoid erosion, stem stability |
| Annual thereafter | Monitor for complications | Glenoid erosion progression? Superior migration? Symptoms warrant revision? |
Outcomes and Prognosis
Functional Outcomes by Indication
| Indication | Pain Relief | ROM | Revision Rate | Notes |
|---|---|---|---|---|
| AVN (intact glenoid) | Excellent (85-90%) | Good (130-150° elevation) | Low (under 10% at 10y) | Best indication for hemiarthroplasty |
| Fracture (tuberosities healed) | Good (75-80%) | Fair (100-120° elevation) | Moderate (15-20% at 10y) | Outcome dependent on tuberosity healing |
| Fracture (tuberosity non-union) | Fair (60-70%) | Poor (under 90° elevation) | High (30-40% at 10y) | Consider revision to reverse TSA |
| OA with glenoid arthritis | Poor (50-60%) | Fair (90-110° elevation) | High (40-50% at 5y) | Hemiarthroplasty alone inadequate - need TSA |
Prognostic Factors
Good Prognosis
- AVN with intact glenoid (best indication)
- Anatomic tuberosity healing (fracture cases)
- Intact rotator cuff preoperatively
- Correct version and height (20-30° retroversion, 5-8mm proud)
- Young age (under 65 years)
- Compliant with therapy (critical for ROM)
Poor Prognosis
- Tuberosity non-union or malunion (fracture)
- Pre-existing cuff dysfunction (fatty infiltration)
- Glenoid arthritis present at time of surgery
- Malversion (under 20° or over 40° retroversion)
- Incorrect height (too proud or too low)
- Elderly with osteoporosis (healing issues)
Tuberosity Healing Predicts Outcome
40-50% anatomic tuberosity healing in fracture hemiarthroplasty. Healed tuberosities: Constant score 65-70, elevation 120°, 80% good-excellent. Non-union: Constant score under 50, elevation under 90°, only 40% good-excellent. Malunion (superior GT): Impingement and pain. This is why reverse TSA has replaced hemiarthroplasty - reverse does not depend on tuberosity healing for function.
Evidence Base and Key Trials
DELPHI Trial: Reverse vs Hemiarthroplasty for Fractures
- Prospective cohort: 62 patients over 65 with 3-4 part PHF
- Reverse TSA vs hemiarthroplasty at 2 years
- Reverse TSA: Constant score 60 vs hemi 48 (p under 0.01)
- Complications: Reverse 29% vs hemi 43%
- Tuberosity non-union: Reverse 15% vs hemi 40%
Systematic Review: Outcomes of Fracture Hemiarthroplasty
- Meta-analysis of 23 studies, 1324 patients
- Tuberosity healing: Anatomic 48%, displaced 37%, resorbed 15%
- Healed tuberosities: Constant 67, poor outcomes 18%
- Non-union: Constant 45, poor outcomes 55%
- Overall complication rate 29%
Glenoid Erosion After Hemiarthroplasty
- Retrospective cohort: 96 hemiarthroplasties, mean follow-up 8 years
- Glenoid erosion developed in 52% by 10 years
- Superior migration in 41% (cuff dysfunction)
- Revision to TSA or reverse in 18%
- Pain scores worse with progression of glenoid wear
Version and Height in Shoulder Arthroplasty
- CT study of 140 normal shoulders for anatomic parameters
- Mean retroversion 24° (range 13-42°)
- Mean head height 8mm above GT apex
- Malversion (under 20° or over 40°) associated with instability
- Height under 5mm or over 10mm associated with poor outcomes
AOANJRR Data on Shoulder Hemiarthroplasty
- Hemiarthroplasty declining: 15% of shoulder arthroplasties (down from 30% in 2010)
- Fracture indication: Reverse TSA now 70% vs hemiarthroplasty 25%
- 5-year revision rate: Hemiarthroplasty 12% vs reverse 8%
- Most common revision reason: Glenoid erosion (45%)
Exam Viva Scenarios
Practice these scenarios to excel in your viva examination
Scenario 1: Fracture Indication and Planning
"A 62-year-old active male presents 10 days after fall with a displaced 4-part proximal humerus fracture. CT shows head split with varus angulation and GT displacement. He is medically fit. How would you assess and manage this patient?"
Scenario 2: Surgical Technique and Version
"You are performing hemiarthroplasty for a 3-part fracture. Walk me through your technique for achieving correct version and height. The trial reduction shows tendency to anterior subluxation with the arm at the side. What is the problem and how do you fix it?"
Scenario 3: Complication Management - Tuberosity Non-Union
"A 58-year-old patient is 9 months post hemiarthroplasty for a 4-part fracture. He has persistent pain and can only elevate to 70 degrees. Radiographs show superior migration of the greater tuberosity with 15mm displacement from the anatomic position. The stem position and version appear satisfactory. How do you manage this complication?"
MCQ Practice Points
Anatomy Question
Q: What is the target retroversion for the humeral component in shoulder hemiarthroplasty? A: 20-30 degrees retroversion relative to the epicondylar axis. Less than 20 degrees causes anterior instability, greater than 40 degrees causes posterior instability and limited internal rotation. The bicipital groove is approximately 30 degrees posterior to the epicondyles, providing a rough intraoperative reference.
Technical Question
Q: What is the optimal height of the humeral stem relative to the greater tuberosity in shoulder hemiarthroplasty? A: 5-8mm proud of the greater tuberosity apex. This restores anatomic head height and proper deltoid/cuff tension. Too high (over 10mm) causes subacromial impingement; too low (under 5mm) reduces deltoid tension and increases superior migration risk with cuff dysfunction.
Complication Question
Q: What is the tuberosity healing rate in hemiarthroplasty for proximal humerus fractures, and what determines outcome? A: 40-50% achieve anatomic tuberosity healing. Healed tuberosities result in good-excellent outcomes (Constant score 65-70, elevation 120 degrees) in 80%. Non-union leads to poor outcomes (Constant under 50, elevation under 90 degrees) in 60%. This is why reverse shoulder arthroplasty has largely replaced hemiarthroplasty - it does not depend on tuberosity healing.
Evidence Question
Q: What does the DELPHI trial show about reverse TSA versus hemiarthroplasty for elderly proximal humerus fractures? A: Reverse TSA superior outcomes: Constant score 60 vs 48 for hemiarthroplasty at 2 years. Complications 29% vs 43%. Tuberosity non-union 15% vs 40%. Reverse TSA provides predictable functional improvement regardless of tuberosity healing, making it the preferred option for elderly (over 70) patients with 3-4 part fractures.
Indication Question
Q: What is the best indication for hemiarthroplasty in current practice? A: Avascular necrosis with intact glenoid cartilage in a young patient. This preserves glenoid bone stock for potential future TSA and provides excellent pain relief (85-90%) and function. Fracture indications now favor reverse TSA in elderly; OA with glenoid arthritis requires TSA not hemiarthroplasty alone.
Australian Context Question
Q: What does the AOANJRR data show about hemiarthroplasty trends in Australia? A: Declining use: Hemiarthroplasty now only 15% of shoulder arthroplasties (down from 30% in 2010). For fractures, reverse TSA is now 70% vs hemiarthroplasty 25%. Five-year revision rate 12% for hemiarthroplasty vs 8% for reverse. Most common revision reason: glenoid erosion (45%) - occurs in over 50% by 10 years.
Australian Context and Medicolegal Considerations
AOANJRR Registry Data
- Hemiarthroplasty declining: 15% of shoulder cases (was 30% in 2010)
- Fracture trend: Reverse TSA 70%, hemiarthroplasty 25%, ORIF 5%
- Revision rate: 12% at 5 years (vs 8% for reverse)
- Glenoid erosion: Most common revision reason (45%)
- Tuberosity failure: Second most common (30%)
- Conversion to reverse: Common salvage for failed hemiarthroplasty
Australian Guidelines
- ACSQHC Surgical Safety: WHO checklist mandatory
- Antibiotic prophylaxis: Cefazolin 2g pre-incision (ASID guidelines)
- DVT prophylaxis: LMWH or aspirin based on risk (Cancer patients high risk)
- Consent standards: Document alternatives (reverse TSA), realistic outcomes
- PBS restrictions: No specific restrictions for hemiarthroplasty implants
- Physiotherapy: Medicare rebate for 5 sessions post-op (limited)
Medicolegal Considerations
Key Documentation and Consent Requirements
Critical consent points to document:
- Tuberosity healing: Only 40-50% achieve anatomic healing in fractures; discuss implications of non-union
- Glenoid erosion risk: 50% by 10 years; may require conversion to TSA or reverse
- Reverse TSA alternative: Discuss evidence showing reverse superior outcomes for elderly fractures
- Functional expectations: Realistic ROM (100-120° elevation), limited ER if tuberosity fails
- Nerve injury risk: Axillary nerve 2-5% (transient in 90%)
- Infection risk: 1-2%; higher in diabetes, smoking
- Revision possibility: 15-20% at 10 years for glenoid erosion or tuberosity failure
Common Litigation Issues
Failure to offer reverse TSA: In elderly patients with fractures, not discussing reverse TSA as alternative (now standard of care) may be considered substandard. Document discussion.
Tuberosity non-union: High rate (40-50%) makes this a known complication, not negligence per se. However, must document proper consent about this risk. Litigation arises if patient claims they would have chosen reverse if properly informed.
Malversion/instability: Version outside 20-40° range leading to instability may be considered technical error. Document intraoperative C-arm confirmation of version.
Glenoid erosion: Known long-term complication. Litigation if hemiarthroplasty performed for OA with existing glenoid arthritis - TSA is standard of care, not hemiarthroplasty alone.
Hospital System Considerations
Public hospitals: Reverse TSA now preferred for fractures in most centers. Hemiarthroplasty may not be stocked; discuss with implant coordinator.
Private hospitals: Insurance coverage generally includes hemiarthroplasty. Gap for uninsured patients approximately AUD 15,000-25,000 (surgeon, anesthetist, hospital, implant).
Rehabilitation: Allied health access variable. Public patients may wait 2-4 weeks for outpatient PT; arrange private PT if affordable for optimal outcomes.
SHOULDER HEMIARTHROPLASTY
High-Yield Exam Summary
Key Anatomy
- •GT position: 5-8mm below stem apex for anatomic head height
- •Version: 20-30° retroversion to epicondylar axis prevents instability
- •Axillary nerve: 5-7cm inferior to acromion, at risk with inferior retraction
- •Bicipital groove: 30° posterior to groove approximates 30° retroversion
- •Subscapularis: Critical for anterior stability, repair to LT with heavy sutures
Indications
- •Best: AVN with intact glenoid in young patient (preserves bone stock)
- •Fracture: 3-4 part in young (under 65) with intact cuff - BUT reverse TSA increasingly preferred
- •OA: Ream-and-run in high-demand young patients (biological glenoid resurfacing)
- •Contraindication: Glenoid arthritis (TSA needed), cuff arthropathy (reverse TSA needed)
Surgical Technique
- •Approach: Deltopectoral, preserve cephalic vein, release subscapularis
- •Version: 20-30° retroversion, use epicondylar axis, confirm with C-arm
- •Height: 5-8mm proud of GT, measure on trials before cementing
- •Tuberosity fixation: Heavy sutures (Number 5), figure-of-8 through stem, vertical mattress to shaft
- •Cement in fractures: Immediate stability for tuberosity healing
Surgical Pearls
- •Anterior instability = insufficient retroversion (under 20°), increase to 25-30°
- •Posterior instability = excessive retroversion (over 40°) or cuff deficiency
- •Tuberosity healing: Anatomic position, solid fixation, protect 6 weeks passive only
- •Trial extensively: Check ROM, stability, impingement before final implant
Complications
- •Tuberosity non-union: 40-50% in fractures, determines outcome - salvage with reverse TSA
- •Glenoid erosion: 50% by 10 years, superior migration, convert to TSA or reverse
- •Instability: 2-5%, anterior if under 20° version, posterior if over 40°
- •Nerve injury: Axillary 2-5% (mostly transient neurapraxia)
- •Infection: 1-2%, DVT prophylaxis essential
Key Evidence and Australian Context
- •DELPHI trial: Reverse TSA superior to hemi for elderly fractures (Constant 60 vs 48)
- •Tuberosity healing: Only 48% anatomic, 37% displaced, 15% resorbed
- •AOANJRR: Hemiarthroplasty declining (15% of cases), reverse replacing for fractures
- •Glenoid erosion: 52% by 10 years, main revision reason (45%)
- •Revision rate: 12% at 5 years for hemiarthroplasty vs 8% for reverse TSA