Hemiarthroplasty for Fracture
Design Rationale and Surgical
Technique
Reza Omid, M.D.
Assistant Professor Orthopaedic Surgery
Shoulder & Elbow Reconstruction
Sports Medicine
Keck School of Medicine of USC
Disclosures
JBJSAm (Editorial Board)
Smith & Nephew (Consultant)
Integra (Consultant)
DeRoyal (Consultant)
Optimal Treatment
• UNKOWN????
• JSES 2011: 1118-1124 (RCT ORIF vs
Non-op)
• JSES 2011: 747-55 (RCT ORIF vs Non-op
• JSES 2011: 1025-1033 (RCT Hemi vs
Non-op)
• JOT 2011 (RCT ORIF vs Non-op)
Hemiarthroplasty
• Older Patients
• Osteopenic Bone
• Fracture-Dislocations
– > 40% Impression Defect
Hemiarthroplasty Technique
Patient Position
Surgical Technique
Extended deltopectoral exposure:
deltoid origin and insertion intact
Proximal Humerus Fracture
Parts
Surgical Technique
Identify the LHB and Tuberosities
Evaluate the rotator cuff injury
Surgical Technique
Remove the humeral head
Evaluate the glenoid
Tuberosity Suture Technique
Place suture at the tendon bone interface
Head Size
Solutions
–removed head is guide
»thickness > radius
–error towards undersize
–check gross appearance
Position of Greater
Tuberosity
Height Relative to Humeral Head
Surgical Technique
Assess the humeral height and version
Trial tuberosity reduction
Mark the stem position
5-8 mm
Height of
the Greater
Tuberosity
Lesser
Tuberosity
Benefits of Titan System
Press fit fracture
No jig needed for
stabilizing trials
Varying body heights
to dial in correct
humeral head height
Primary Proximal Bodies
Small
Head Options
Head Size
Spherical Ø
38x14*
40x15*
42x16
44x16
44x19
46x14
46x17
46x20
48x15
48x18
48x21
50x19
50x22
52x20
41
43
45
48
45
54
49
47
56
51
49
53
51
55
*Eccentric Only
Glenoid Options
Standard
Large
Press-fit Stems
***Any size primary or fracture body
can be used with any size
press fit or cemented stem
Tuberosity Height = Prosthetic
Height
5-8 mm
Height of
the Greater
Tuberosity
Lesser
Tuberosity
Determining Height
–Superior border of Pectoralis tendon
(5.6cm±0.5cm)
–Side to Side comparison (x-ray)
–View calcar contour (gothic arch)
Determining Height
Proximal Humerus Fracture
Humeral Version
Version
Effect of Incorrect Version
Too Anteverted
Too Retroverted
Biceps Groove Version
Groove shifts
medially from
proximal to distal,
changing
retroversion
values 15.9°
from the upper to
lower part of the
bicipital groove
Surgical Technique
Prepare the fixation sutures for ORIF of the tuberosities.
– 2-3 vertical and 2 horizontals, one medial one lateral
Surgical Technique
Tuberosity fixation and bone
graft
Biceps tenodesis
Wound drains and closure
Surgical Technique
4 Part Fracture Repair
Factors Affecting Outcome
•
•
•
•
Bone density
Rotator cuff tissue quality
Tuberosity healing
Restoration of anatomic humeral head
height
• Restoration of anatomic humeral
version
• Rehabilitation
Reverse for Fracture
• Age >70-75 (I will consider for age >65)
• Tuberosities heal more predictably and
function is not as dependent on tuberosity
healing
• More predictable outcome than with hemi
• Best outcome of a hemi is better than best
outcome of a reverse
Thank You