Proximal Humerus Fracture | Tuberosity Reconstruction | Alternative to TSA
- 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: Common late complication - superior migration from rotator cuff dysfunction
- Global trend: National registries (AOANJRR, NJR, AJRR) show hemiarthroplasty declining - reverse arthroplasty preferred for fractures
- “Sebastia-Forcada RCT: reverse arthroplasty beats hemiarthroplasty for elderly fractures (Constant 56 vs 40) - reverse function is independent of tuberosity healing
- “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°
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.
Stem proud 5-8mm above greater tuberosity. Retroversion 20-30° relative to epicondylar axis. Too proud = impingement; too low = cuff dysfunction.
Modern trend: Reverse shoulder arthroplasty superior outcomes for elderly proximal humerus fractures. Hemiarthroplasty reserved for young, high-demand patients with intact rotator cuff.
50% by 10 years develop glenoid arthritis. Superior migration from rotator cuff insufficiency. Warn patients of potential conversion to TSA or reverse.
- Pathology
- 3-4 part fracture
- Treatment
- Hemiarthroplasty + tuberosity repair
- Key Pearl
- Best chance for tuberosity healing
- Pathology
- 3-4 part fracture
- Treatment
- Reverse shoulder arthroplasty
- Key Pearl
- Superior outcomes, tuberosity healing not critical
- Pathology
- AVN without glenoid arthritis
- Treatment
- Hemiarthroplasty (ream-and-run)
- Key Pearl
- Preserves glenoid bone stock for future TSA
- Pathology
- Glenoid arthritis present
- Treatment
- Total shoulder arthroplasty
- Key Pearl
- Hemiarthroplasty alone gives poor pain relief
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)
The Sebastia-Forcada blinded randomised controlled trial (2014) demonstrated reverse shoulder arthroplasty gives superior outcomes compared to hemiarthroplasty for elderly displaced proximal humerus fractures (mean Constant 56 vs 40, forward elevation 120° vs 80°). Crucially, reverse function was independent of tuberosity healing whereas hemiarthroplasty function depended on it. Hemiarthroplasty is now reserved for young, high-demand patients with an intact cuff where anatomic tuberosity reconstruction is achievable.
- 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
- 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
Classification and Indications
Proximal Humerus Fracture
Neer Classification guides surgical decision:
- Age/Cuff Status
- Young (under 65), intact cuff
- Treatment
- Hemiarthroplasty + tuberosity repair
- Rationale
- Potential for tuberosity healing and good function
- Age/Cuff Status
- Young (under 65), intact cuff
- Treatment
- Hemiarthroplasty + tuberosity repair
- Rationale
- Head AVN inevitable; preserve glenoid if possible
- Age/Cuff Status
- Elderly (over 70)
- Treatment
- Reverse shoulder arthroplasty
- Rationale
- Superior outcomes; tuberosity healing not critical
- Age/Cuff Status
- Any age, articular comminution
- Treatment
- Hemiarthroplasty or reverse
- Rationale
- Head reconstruction impossible
Sebastia-Forcada RCT (2014): Reverse arthroplasty superior to hemiarthroplasty for elderly complex fractures. At a mean of 2 years: Constant score 56 vs 40 and forward elevation 120° vs 80°. Reverse does not depend on tuberosity healing for function - the deltoid provides power. Reserve hemiarthroplasty for young patients with an intact cuff where anatomic reconstruction is possible.
Fracture Imaging Examples
Anatomy and Biomechanics
Proximal Humerus Surgical Anatomy
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.
- Clinical Significance
- Supraspinatus, infraspinatus, teres minor insertion
- Surgical Relevance
- Must sit 5-8mm below stem; controls elevation and ER
- Clinical Significance
- Subscapularis insertion
- Surgical Relevance
- Medial to bicipital groove; controls IR and stability
- Clinical Significance
- Long head biceps anatomic landmark
- Surgical Relevance
- Version reference - 30° posterior to groove = 30° retroversion
- Clinical Significance
- 5-7cm inferior to acromion anteriorly
- Surgical Relevance
- 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.
Clinical Assessment
- 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
- 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
- Muscle Tested
- Supraspinatus
- Interpretation
- Weakness = poor outcome for hemiarthroplasty
- Muscle Tested
- Infraspinatus, teres minor
- Interpretation
- Essential for ER after tuberosity repair
- Muscle Tested
- Subscapularis
- Interpretation
- Critical for anterior stability
- Muscle Tested
- Chronic massive tear
- Interpretation
- Consider reverse TSA instead of hemi
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.
Differential Diagnosis
The painful, dysfunctional shoulder being considered for arthroplasty has several mimics. Distinguishing them changes whether arthroplasty is indicated at all, and if so, which type.
- Distinguishing features
- Acute trauma, bruising, crepitus, fracture pattern on plain films
- Key investigation
- CT with 3D reconstruction
- Implication
- Arthroplasty (hemiarthroplasty or reverse) if unreconstructable
- Distinguishing features
- Chronic stiffness, posterior glenoid wear, intact cuff
- Key investigation
- Plain films, CT for glenoid morphology (Walch)
- Implication
- Anatomic TSA preferred over hemiarthroplasty for function
- Distinguishing features
- Pseudoparalysis, superior migration, acromiohumeral interval reduced
- Key investigation
- Plain films plus MRI/ultrasound for cuff
- Implication
- Reverse arthroplasty - hemiarthroplasty will fail
- Distinguishing features
- Steroid/alcohol history, crescent sign, preserved glenoid early
- Key investigation
- MRI (subchondral oedema, extent)
- Implication
- Hemiarthroplasty/resurfacing if glenoid spared
- Distinguishing features
- Polyarthritis, erosions, poor bone/soft tissue quality
- Key investigation
- Serology plus radiographs
- Implication
- Often TSA or reverse depending on cuff and bone stock
- Distinguishing features
- Fever, raised inflammatory markers, effusion
- Key investigation
- Aspiration, CRP/ESR, cultures
- Implication
- Absolute contraindication to primary arthroplasty
PROUDStem Version and Height Assessment
Hook:Stem should be PROUD but not too proud - Goldilocks height 5-8mm above greater tuberosity!
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
- 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
- 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
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
- 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
- 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 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
- 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
- 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
- Cause
- Soft tissue contracture, incorrect height
- Solution
- Check stem height (may be too proud); mobilize soft tissues; use traction sutures
- Cause
- Version under 20° retroversion
- Solution
- Remove stem, cement in more retroversion (25-30°)
- Cause
- Version over 40° retroversion, posterior cuff deficiency
- Solution
- Reduce retroversion; check posterior cuff intact; may need reverse if cuff deficient
- Cause
- Osteoporotic bone, eccentric reaming
- Solution
- Extend stem distally; cerclage cables; consider long-stem implant
Optimising Tuberosity Healing Beyond Sutures
The topic repeatedly identifies tuberosity union as the Achilles heel of fracture hemiarthroplasty and details the suture technique. The implant and biological strategies that complement the sutures deserve equal weight, because they are what an examiner expects when asking "how do you maximise tuberosity healing?".
- Rationale
- Lets the tuberosities appose living bone rather than a bulky metal shoulder; built-in holes carry the figure-of-8 sutures and the roughened/coated surface encourages bone ongrowth
- Rationale
- Tuberosities heal to living bone and graft, not to an interposed cement mantle
- Rationale
- Packed around the stem fin and beneath the tuberosities to bridge tuberosity-to-shaft and tuberosity-to-tuberosity
- Rationale
- A too-proud stem blocks tuberosity reduction and over-tensions the cuff; correct height lets the tuberosities sit and heal
Because tuberosity union dictates the result, the full answer to "how do you maximise healing?" goes beyond heavy figure-of-8 sutures. Use a fracture-specific stem (low-profile proximal body with suture eyelets and a fenestrated, often hydroxyapatite-coated surface) so the tuberosities appose living bone rather than metal; cement only the diaphysis and keep the tuberosity zone cement-free; and graft autologous cancellous bone from the resected head around the fin and under the tuberosities. Combine that with anatomic height and version and protected, passive-only rehabilitation for six weeks. When these cannot be achieved - poor bone, atrophic tuberosities, the elderly - reverse arthroplasty is more reliable because its function does not depend on tuberosity healing.
HEALSTuberosity Fixation Principles
Hook:Tuberosity HEALS when fixation is solid - think figure-of-8 sutures creating a healing scaffold!
Complications
- Incidence
- 40-50% in fractures
- Risk Factors
- Osteoporosis, poor fixation, early motion
- Management
- Observation if minimal symptoms; revision if painful with poor function
- Incidence
- 50% by 10 years
- Risk Factors
- Cuff dysfunction, superior migration, high activity
- Management
- Convert to TSA or reverse TSA if painful
- Incidence
- 2-5%
- Risk Factors
- Malversion (under 20° or over 40°), subscapularis failure
- Management
- Anterior: Repair subscapularis, consider glenoid component. Posterior: Revision to correct version
- Incidence
- 1-2% overall
- Risk Factors
- Diabetes, smoking, prolonged surgery
- Management
- Early (under 3 weeks): I&D, retain implant. Late: Explant, spacer, reimplant
- Incidence
- 2-5%
- Risk Factors
- Inferior retractor, traction, dissection
- Management
- Usually neurapraxia - recovers 3-6 months. EMG at 6 weeks if no recovery
- Incidence
- 2-3%
- Risk Factors
- Trauma, osteoporosis, uncemented stems
- Management
- Above stem: ORIF. At stem: Revision to long stem. Below stem: ORIF with cables
- Incidence
- 10-15%
- Risk Factors
- Inadequate therapy, capsular contracture
- Management
- Aggressive PT; manipulation under anesthesia if under 6 months; arthroscopic release if chronic
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.
PAINHemiarthroplasty Complications to Discuss
Hook:PAIN is the main complication of hemiarthroplasty - especially from glenoid erosion!
Glenoid Erosion: Recognition and Conversion Decision
Glenoid erosion is named throughout as the characteristic late failure (around half by ten years) and the leading registry reason for revision, but how to recognise, follow and act on it is never developed. Because a metal head articulates directly on native glenoid, erosion is intrinsic to every hemiarthroplasty.
- Detail
- Metal head on native glenoid cartilage/bone; accelerated by rotator-cuff insufficiency (superior migration) and by performing hemiarthroplasty on an already-arthritic glenoid
- Detail
- Serial AP (joint-space loss; reduced acromiohumeral interval signals cuff failure) and axillary views (posterior/central wear, medialisation); pain lags behind radiographic erosion; CT to quantify glenoid bone stock before any revision
- Detail
- Convert to anatomic total shoulder arthroplasty if glenoid bone stock is adequate
- Detail
- Convert to reverse total shoulder arthroplasty
- Detail
- Observe with serial imaging - pain and function, not radiographs alone, drive revision
Progressive glenoid erosion is the characteristic late failure of hemiarthroplasty (roughly half by ten years) and the leading registry reason for revision, because a metal head articulates directly on native glenoid - accelerated by rotator-cuff insufficiency (superior migration with a reduced acromiohumeral interval) and by performing hemiarthroplasty on an already-arthritic glenoid. Follow with serial AP and axillary films, obtain CT to quantify glenoid bone stock before revising, and let symptoms (not radiographs alone) drive the decision: concentric wear with an intact cuff converts to an anatomic total shoulder, whereas eccentric wear or cuff deficiency with superior escape converts to a reverse.
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
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
- Assessment
- Wound check, begin PT
- Key Points
- Remove sutures/staples; confirm PT started; pain control adequate
- Assessment
- X-ray, advance therapy
- Key Points
- Fracture: Tuberosity healing? If yes, start active-assisted. Non-fracture: Check component position, advance strengthening
- Assessment
- ROM and function assessment
- Key Points
- Expected 100-120° elevation, 30-40° ER. If plateau, consider manipulation
- Assessment
- Outcome scores, imaging
- Key Points
- ASES or Constant score. X-ray: Tuberosity position, glenoid erosion, stem stability
- Assessment
- Monitor for complications
- Key Points
- Glenoid erosion progression? Superior migration? Symptoms warrant revision?
Outcomes and Prognosis
Functional Outcomes by Indication
- Pain Relief
- Excellent (85-90%)
- ROM
- Good (130-150° elevation)
- Revision Rate
- Low (under 10% at 10y)
- Notes
- Best indication for hemiarthroplasty
- Pain Relief
- Good (75-80%)
- ROM
- Fair (100-120° elevation)
- Revision Rate
- Moderate (15-20% at 10y)
- Notes
- Outcome dependent on tuberosity healing
- Pain Relief
- Fair (60-70%)
- ROM
- Poor (under 90° elevation)
- Revision Rate
- High (30-40% at 10y)
- Notes
- Consider revision to reverse TSA
- Pain Relief
- Poor (50-60%)
- ROM
- Fair (90-110° elevation)
- Revision Rate
- High (40-50% at 5y)
- Notes
- Hemiarthroplasty alone inadequate - need TSA
Prognostic Factors
- 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)
- 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)
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.
Guidelines, Registries & Global Practice
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
- Position
- Most proximal humeral fractures are managed non-operatively with early rehabilitation; surgery is individualised. When arthroplasty is chosen for fracture, reverse arthroplasty is increasingly preferred in older patients
- Evidence basis
- Trial evidence (including PROFHER) showing no benefit of routine surgery over non-operative care
- Position
- Acknowledges limited high-level evidence; supports shared decision-making. For arthritic shoulders with an intact cuff, total shoulder arthroplasty is favoured over hemiarthroplasty for function
- Evidence basis
- Systematic-review based guidance; RCT and Cochrane data on TSA vs hemiarthroplasty
- Position
- Defines fracture morphology and arthroplasty indications; emphasises anatomic tuberosity reconstruction when hemiarthroplasty is used and recognises the shift to reverse for elderly fracture
- Evidence basis
- Expert consensus plus comparative cohort/RCT data
- Position
- Reverse arthroplasty is the preferred arthroplasty for displaced fractures in the elderly; hemiarthroplasty retained for younger patients with reconstructable tuberosities and intact cuff
- Evidence basis
- European registry and comparative trial data
Registry Evidence
- AOANJRR, NJR, AJRR all show stemmed hemiarthroplasty declining as a share of shoulder replacement
- Reverse arthroplasty has become the dominant arthroplasty for acute fracture across these registries
- Cumulative revision is consistently higher after hemiarthroplasty than after reverse or anatomic TSA
- Late failure mode: painful glenoid erosion and rotator cuff failure dominate revision reasons
- Safe surgery: WHO Surgical Safety Checklist used internationally
- Antibiotic prophylaxis: first-generation cephalosporin (e.g. cefazolin) within 60 minutes of incision per international consensus
- VTE prophylaxis: risk-stratified mechanical and/or pharmacological prophylaxis (upper-limb arthroplasty is comparatively low VTE risk)
- Consent: document the reverse arthroplasty alternative, tuberosity-healing risk and glenoid-erosion risk
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
Critical consent points to document:
- Tuberosity healing: only around half achieve anatomic healing in fractures; discuss the functional implications of non-union
- Glenoid erosion risk: a recognised long-term complication that may require conversion to TSA or reverse arthroplasty
- Reverse arthroplasty alternative: discuss the randomised evidence showing reverse gives superior outcomes for elderly fractures
- Functional expectations: realistic motion (around 100-120° elevation), with limited external rotation if the tuberosity fails
- Nerve injury risk: axillary nerve injury in a small percentage, usually transient
- Infection risk: low single-figure percentage, higher with diabetes and smoking
- Revision possibility: a meaningful minority require revision within 10 years for glenoid erosion or tuberosity failure
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.
MCQ Practice Points
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.
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.
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.
Q: What does the Sebastia-Forcada randomised trial show about reverse arthroplasty versus hemiarthroplasty for elderly proximal humerus fractures? A: Reverse arthroplasty superior outcomes: in this blinded RCT of patients over 70, mean Constant score was 56 vs 40 and forward elevation 120° vs 80° favouring reverse. In the hemiarthroplasty group only 56.6% of tuberosities healed and function depended on healing, whereas reverse function was independent of tuberosity healing - making reverse the preferred option for elderly patients with complex fractures.
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.
Q: What do national joint registries show about hemiarthroplasty trends? A: Declining use worldwide: across the AOANJRR (Australia), NJR (UK) and AJRR (USA), stemmed hemiarthroplasty has fallen substantially as a proportion of shoulder replacement and reverse arthroplasty has become the dominant choice for acute fracture. Registries consistently report higher cumulative revision after hemiarthroplasty than after reverse or anatomic total shoulder arthroplasty, with painful glenoid erosion and cuff failure the characteristic late failure modes.
Exam Viva Scenarios
Practise clinical reasoning and management decisions out loud
“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?”
“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?”
“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?”
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 Global Practice
- Sebastia-Forcada RCT: reverse arthroplasty superior to hemi for elderly fractures (Constant 56 vs 40, elevation 120° vs 80°)
- Kontakis systematic review: tuberosity complications ~11%, proximal migration ~7%, mean Constant ~57
- Singh Cochrane: TSA gives better function than hemiarthroplasty for arthritic shoulders
- Registries (AOANJRR/NJR/AJRR): hemiarthroplasty declining, reverse now dominant for fracture
- Glenoid erosion and cuff failure are the characteristic late reasons for revision
Evidence Base and Key Trials
Sebastia-Forcada RCT: Reverse vs Hemiarthroplasty for Acute Fractures
- Blinded RCT: 62 patients over 70 with acute complex proximal humeral fractures, randomised to reverse (RSA) or hemiarthroplasty (HA)
- Mean Constant score 56.1 (RSA) vs 40.0 (HA), p = 0.001
- Forward elevation 120° (RSA) vs 80° (HA); abduction 113° vs 79°
- In the HA group only 56.6% of tuberosities healed and 30% resorbed; failure of tuberosity healing predicted worse function
- Six HA patients needed revision to RSA for proximal migration; functional outcome of RSA was independent of tuberosity healing
Systematic Review: Hemiarthroplasty for Proximal Humeral Fractures
- Systematic review of 16 studies, 810 hemiarthroplasties (mean age 67.7 years, mean follow-up 3.7 years), mostly four-part fractures
- Mean active anterior elevation 105.7° and abduction 92.4° — function modest even in pooled data
- Tuberosity fixation/healing complications in 11.15% of cases; proximal migration of the humeral head in 6.8%
- Superficial infection 1.55%, deep infection 0.64%
- Mean Constant score 56.6; most patients had little or no pain but marked persistent functional limitation
Cochrane Review: Total Shoulder Arthroplasty vs Hemiarthroplasty for OA
- Cochrane review of 7 RCTs (238 patients) on surgery for shoulder osteoarthritis
- Two RCTs (88 patients) directly compared hemiarthroplasty with total shoulder arthroplasty
- Hemiarthroplasty gave significantly worse ASES function at 24-34 months (mean difference -10.05, 95% CI -18.97 to -1.13)
- No significant difference in pain, quality of life or adverse events between hemiarthroplasty and TSA
- Non-significant trend toward higher revision after hemiarthroplasty (risk ratio 6.18, 95% CI 0.77 to 49.52)
Ream-and-Run vs Total Shoulder Arthroplasty for Glenohumeral Arthritis
- Case-matched study: 35 ream-and-run (nonprosthetic glenoid arthroplasty with hemiarthroplasty) patients vs matched TSA controls
- Cohort predominantly young active men (mean age 56 years)
- Simple Shoulder Test scores converged by 2-3 years (8.9 vs 9.4 at 24 months; 9.5 vs 10.0 at 36 months)
- TSA recovered faster early; ream-and-run reached comparable function but more slowly
- Ream-and-run avoids a polyethylene glenoid component and preserves glenoid bone stock
National Joint Registry Evidence: Decline of Shoulder Hemiarthroplasty
- Across the AOANJRR, NJR and AJRR, stemmed hemiarthroplasty has fallen sharply as a share of shoulder replacement, displaced by reverse arthroplasty
- For acute proximal humeral fracture, reverse arthroplasty is now the dominant arthroplasty choice in all three registries
- Registries consistently report higher cumulative revision after hemiarthroplasty than after reverse or anatomic total shoulder arthroplasty
- Painful glenoid erosion and rotator cuff failure are leading recorded reasons for revision of hemiarthroplasty
Reaming Retroverted Glenoids: Limits of Glenoid-Preserving Surgery
- Computer-simulation study of 71 CT-scanned B2 (biconcave, retroverted) glenoids
- Correcting version by anterior reaming required about 5 mm of reaming to reach 15° and 8 mm to reach 10° of retroversion
- Glenoids with native retroversion greater than 25° had a much higher peripheral peg perforation rate (56% vs 23%; relative risk 2.4)
- Severe retroversion correction left more glenoid face on poor-quality cancellous bone
- Authors advise considering alternatives to corrective reaming when native version exceeds 25°