Shoulder hemiarthroplasty is a surgical procedure used to treat complex fractures of the upper arm bone (proximal humerus) when traditional fixation with plates and screws is not feasible. In this operation, the damaged humeral head is replaced with a prosthetic implant while the shoulder socket (glenoid) is preserved. This procedure helps relieve pain, restore strength, and maintain shoulder stability in selected patients.
How Common It Is and Who Gets It? (Epidemiology)
Shoulder hemiarthroplasty has historically been a standard treatment for severe proximal humerus fractures, particularly among older adults. Although its use has declined with the increasing popularity of reverse shoulder arthroplasty, it remains an important option for patients with intact rotator cuffs and suitable bone quality. The procedure is most common in individuals over 60 years old, especially after fractures involving multiple bone fragments or disrupted blood supply to the humeral head.
Why It Happens – Causes (Etiology and Pathophysiology)
Hemiarthroplasty is typically indicated for fractures that cannot be reliably fixed with plates and screws or when bone healing is unlikely. The main causes include:
- Comminuted fractures: Multiple fracture fragments that cannot be reconstructed.
- Disrupted blood supply: Loss of blood flow to the humeral head can lead to bone death (osteonecrosis).
- Failed fixation: When prior surgical repair has failed or the bone is too weak to hold hardware.
- Complex deformities: In patients where bone alignment cannot be restored with standard techniques.
By replacing the humeral head with a prosthesis, hemiarthroplasty restores the shape and length of the upper arm bone while reducing pain and preventing further joint damage.
How the Body Part Normally Works? (Relevant Anatomy)
The shoulder joint, or glenohumeral joint, connects the ball-shaped head of the humerus to the glenoid cavity of the scapula (shoulder blade). Stability and motion depend on the rotator cuff muscles and the surrounding ligaments. The rotator cuff (supraspinatus, infraspinatus, subscapularis, and teres minor) maintains the humeral head in its socket during movement. Damage to these structures or the humeral head disrupts joint alignment and causes pain, stiffness, and loss of motion.
What You Might Feel – Symptoms (Clinical Presentation)
Patients with complex shoulder fractures or joint degeneration may experience:
- Severe shoulder pain and swelling
- Inability to lift or rotate the arm
- Grinding or instability in the joint
- Bruising and tenderness around the shoulder
- Weakness and limited range of motion
These symptoms often worsen after trauma or in degenerative conditions like osteonecrosis.
How Doctors Find the Problem? (Diagnosis and Imaging)
Diagnosis begins with a thorough clinical evaluation, followed by imaging tests. X-rays identify the fracture pattern and degree of displacement, while CT scans provide detailed 3D visualization for surgical planning. MRI scans may be used to assess the rotator cuff’s condition. Blood tests and medical history reviews help rule out infection or other underlying conditions before surgery.
Procedure Types or Techniques (Classification)
Hemiarthroplasty can be performed using different surgical approaches, most commonly the deltopectoral approach. The major surgical steps include:
- Positioning: The patient is placed in a semi-seated (beach-chair) position under anesthesia.
- Exposure: A deltopectoral incision allows access to the shoulder joint.
- Tendon Management: The long head of the biceps tendon is detached and anchored to minimize future pain.
- Implant Placement: The damaged humeral head is removed. The prosthetic stem and metal head are inserted and cemented into place at the correct height and angle.
- Tuberosity Fixation: The greater and lesser tuberosities are reattached using sutures and bone grafts to promote healing and restore tendon function.
- Closure: The incision is closed, and the arm is immobilized in a sling.
Other Problems That Can Feel Similar (Differential Diagnosis)
Conditions that can resemble complex shoulder fractures or joint degeneration include:
- Severe rotator cuff tears
- Shoulder dislocation
- Osteoarthritis of the shoulder
- Avascular necrosis of the humeral head
- Proximal humerus nonunion
Accurate imaging helps differentiate these conditions and determine whether hemiarthroplasty is appropriate.
Treatment Options
Shoulder hemiarthroplasty replaces only the humeral head while preserving the native socket. It provides pain relief and restores some motion in patients whose fractures cannot be reconstructed. In comparison:
- Total shoulder arthroplasty (TSA) replaces both the humeral head and the glenoid.
- Reverse shoulder arthroplasty (RSA) reverses the joint’s ball-and-socket orientation, relying on the deltoid instead of the rotator cuff for movement.
The choice depends on rotator cuff integrity, bone quality, and patient activity level.
Recovery and What to Expect After Surgery
Postoperative recovery requires patience and strict adherence to rehabilitation. The arm remains in a sling for 4 to 6 weeks. Passive exercises begin after 4 weeks to prevent stiffness, followed by active-assisted and strengthening exercises after 8 weeks. Full recovery typically takes 4 to 6 months, depending on fracture complexity and healing of the tuberosities.
Possible Risks or Side Effects (Complications)
Common complications include:
- Tuberosity nonunion or malunion, leading to weakness or poor motion
- Component malpositioning, causing instability
- Rotator cuff failure
- Persistent pain or stiffness
- Glenoid wear (erosion of the socket)
- Infection or nerve injury
Cuff failure occurs in nearly half of cases, while tuberosity complications are reported in over 40%. Proper surgical alignment and rehabilitation significantly reduce these risks.
Long-Term Outlook (Prognosis)
Patient satisfaction after shoulder hemiarthroplasty is generally high when the rotator cuff and tuberosities heal properly. Studies show that approximately 75% of patients report good to excellent outcomes, with an average forward flexion of about 98° and external rotation of 22°. Pain relief strongly influences satisfaction more than range of motion. Some patients may later require conversion to reverse shoulder arthroplasty if function declines.
Out-of-Pocket Costs
If your shoulder hemiarthroplasty is required due to a work-related injury, Workers’ Compensation will cover all associated medical expenses, including surgery, hospitalization, and rehabilitation. You will not have any out-of-pocket expenses, as the employer’s insurance carrier directly pays for all approved procedures.
No-Fault Insurance
If your shoulder replacement surgery is related to an automobile accident, No-Fault Insurance will typically cover the total cost of treatment, including surgery and postoperative care. The only potential out-of-pocket cost may be a small deductible or co-payment depending on your policy.
Example
Robert Lewis underwent a shoulder hemiarthroplasty (CPT 23470) to replace the humeral head after a fracture. His estimated Medicare out-of-pocket cost was $282.66. Since Robert had supplemental insurance through Blue Cross Blue Shield, his remaining balance was fully covered, leaving him with no out-of-pocket expenses for the procedure.
Frequently Asked Questions (FAQ)
Q. What is shoulder hemiarthroplasty?
A. Shoulder hemiarthroplasty is a surgical procedure where only the head of the humerus (upper arm bone) is replaced with an artificial implant, leaving the natural socket (glenoid) intact.
Q. When is shoulder hemiarthroplasty recommended?
A. It is recommended when there is damage to the humeral head but the glenoid is still in good condition, such as in certain fractures or cases of arthritis affecting only the humeral head.
Q. What conditions can be treated with shoulder hemiarthroplasty?
A. Conditions include severe fractures of the humeral head, avascular necrosis, and certain cases of osteoarthritis or rheumatoid arthritis where the glenoid is unaffected.
Q. What are the advantages of shoulder hemiarthroplasty?
A. Advantages include preservation of the natural glenoid, less bone removal, and potentially shorter surgery time and recovery.
Q. How is shoulder hemiarthroplasty different from total shoulder replacement?
A. In shoulder hemiarthroplasty, only the humeral head is replaced, whereas in total shoulder replacement both the humeral head and the glenoid are replaced with prosthetic components.
Q. What is the typical recovery process after shoulder hemiarthroplasty?
A. Recovery involves immobilization in a sling followed by physical therapy to restore range of motion and strength over several weeks to months.
Q. What type of anesthesia is used for shoulder hemiarthroplasty?
A. General anesthesia or a regional nerve block is typically used during the procedure.
Q. How long does shoulder hemiarthroplasty surgery take?
A. The procedure usually takes about one to two hours.
Q. What are the risks of shoulder hemiarthroplasty?
A. Risks include infection, nerve injury, prosthesis loosening, stiffness, and continued pain.
Q. Can patients return to normal activities after shoulder hemiarthroplasty?
A. Most patients can return to daily activities and low-impact sports after rehabilitation, but some limitations may remain.
Q. How long does the implant last after shoulder hemiarthroplasty?
A. Implants can last many years, but longevity depends on activity level, bone quality, and other patient-specific factors.
Q. Is physical therapy necessary after shoulder hemiarthroplasty?
A. Yes, physical therapy is essential for regaining shoulder motion, strength, and function after surgery.
Q. Who is not a good candidate for shoulder hemiarthroplasty?
A. Patients with glenoid damage, severe rotator cuff tears, or poor bone quality may not be ideal candidates for this procedure.
Summary and Takeaway
Shoulder hemiarthroplasty remains a valuable treatment for patients with complex fractures, particularly when the rotator cuff and glenoid are intact. The success of the procedure depends on tuberosity healing, proper implant placement, and structured rehabilitation. While newer procedures like reverse shoulder arthroplasty offer alternatives, hemiarthroplasty continues to deliver excellent pain relief and function for well-selected patients.
Clinical Insight & Recent Findings
A recent study known as the SHeRPA trial compared reverse shoulder arthroplasty (RSA) and hemiarthroplasty (HA) in patients aged 65 and older with complex three- or four-part proximal humerus fractures.
Conducted across multiple UK hospitals, this randomized controlled trial found that RSA provided significantly better shoulder function and patient satisfaction at 12 months, with a mean Constant Score of 51.1 compared to 35.0 for HA, and no increased risk of complications. These findings reinforce that while hemiarthroplasty remains valuable for selected patients with intact rotator cuffs and adequate bone stock, reverse shoulder arthroplasty achieves more reliable outcomes in elderly individuals, particularly those with compromised cuff function.
The results highlight a shift toward RSA as the preferred option for complex fractures in older adults, while HA continues to serve as an alternative when joint anatomy and soft tissue integrity are preserved. (“Study of reverse versus hemiarthroplasty outcomes in elderly shoulder fractures – see PubMed.”)
Who Performs This Surgery? (Specialists and Team Involved)
Shoulder hemiarthroplasty is performed by orthopedic surgeons specializing in shoulder and upper extremity surgery. The surgical team may include anesthesiologists, physician assistants, nurses, and physical therapists.
When to See a Specialist?
You should see an orthopedic specialist if you experience severe shoulder pain after trauma, have limited arm motion, or X-rays reveal a complex fracture that cannot be repaired with standard fixation.
When to Go to the Emergency Room?
Seek immediate care if you experience severe shoulder pain, visible deformity after trauma, fever, redness, or drainage from the surgical site. Sudden weakness or loss of arm function after surgery also requires urgent evaluation.
What Recovery Really Looks Like?
Recovery involves gradual progress. Pain and stiffness are common early on. The sling is used for several weeks, followed by physical therapy to rebuild motion and strength. Full function returns gradually over months, with pain improvement preceding strength gains.
What Happens If You Delay Surgery?
Delaying treatment for a complex shoulder fracture can result in bone collapse, deformity, and chronic pain. This may eventually make surgical reconstruction more difficult and reduce the likelihood of full recovery.
How to Prevent Recurrence or Failure?
Following all postoperative and rehabilitation instructions is crucial. Avoid lifting or pushing with the affected arm during early healing. Proper implant alignment, rotator cuff care, and consistent physical therapy help prevent complications and ensure long-term success.
Nutrition and Bone or Joint Health
A balanced diet rich in calcium, vitamin D, and protein supports bone healing after surgery. Avoid smoking and excessive alcohol, as they impair bone health and recovery.
Activity and Lifestyle Modifications
After recovery, low-impact activities such as walking and gentle swimming are encouraged. Avoid heavy lifting or repetitive overhead movements. With proper care, most patients can return to daily activities comfortably and maintain long-term shoulder function.
Dr. Vedant Vaksha
I am Vedant Vaksha, Fellowship trained Spine, Sports and Arthroscopic Surgeon at Complete Orthopedics. I take care of patients with ailments of the neck, back, shoulder, knee, elbow and ankle. I personally approve this content and have written most of it myself.
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