Shoulder Hemiarthroplasty

Shoulder hemiarthroplasty is a shoulder replacement in which the damaged humeral head is replaced with a prosthetic humeral head.

Shoulder arthroplasty is a rapidly evolving area of orthopedics focused on treating specific, painful ailments of the glenohumeral articulation. Broadly, shoulder arthroplasty encompasses surgeries using hemiarthroplasty (humeral prosthesis without replacement of the glenoid), total shoulder arthroplasty (TSA; humeral prosthesis with glenoid resurfacing via prosthesis), and reverse total shoulder replacement (humeral cup prosthesis with glenosphere implantation).[1, 2, 3]

Musculoskeletal disorders account for a high percentage of US healthcare expenditures and are the largest cause of disability.[4] Nearly 10% of adults report experiencing shoulder pain, which makes the shoulder the second most common joint for chronic pain.[4]  Although much less common than lower-extremity arthroplasties, shoulder arthroplasties have grown at annual rates between 6% and 13%.[5] Approximately 53,000 shoulder replacement procedures are performed annually in the United States.[6]  Between 2000 and 2010, there was a 1.9-fold increase in the number of hemiarthroplasties performed in the United States.[7]  

The first shoulder arthroplasty, performed in 1893, is credited to the French surgeon Jules Emile Péan, who inserted a platinum-and-rubber implant into a patient who had glenohumeral destruction secondary to tuberculosis and refused amputation.[8] It is Charles Neer, however, who is credited with pioneering modern shoulder arthroplasty. Dr Neer originally designed the humeral head prosthesis for the treatment of fractures about the humeral head and later went on to describe shoulder arthroplasty in the treatment of glenohumeral arthritis.[9, 10]

Numerous shoulder prostheses have evolved since their introduction in the early 1950s, with the most current prostheses being modular systems made of cobalt-chrome alloy. Options offered by modern humeral prostheses include varying sizes of head length and diameter to match patient anatomy and facilitate soft-tissue balancing, varying stem lengths, smooth or coated stems, and cemented or cementless humeral component stems. The specific humeral components employed are dependent on the surgical indications, the patient's anatomy, and the surgical history.[3]

Subsequent advances by Jon JP Warner, Chief of the Shoulder Service in the Boston Shoulder Institute at the Massachusetts General Hospital (MGH), have helped further improve shoulder arthroplasty by emphasizing innovation and healthcare economics.[4, 11, 12] Dr Warner is a pioneer in virtual patient-specific planning and value-based care in shoulder surgery.

Broadly, indications for shoulder hemiarthroplasty can be divided into those for acute fractures and those for chronic shoulder disease. Here, general indications will be presented and disease-specific indications will be discussed. With each indication, special attention must be paid to the integrity of each functional unit of the patient's shoulder, along with expected patient goals and outcomes.

Goals of hemiarthroplasty include relief of pain, improvement in overhead motion, and improvement in strength with overhead activities. Unrealistic expectations require additional patient education about possible postoperative limitations and lifestyle modifications, which may represent a contraindication to any type of arthroplasty if they persist.

General indications for shoulder hemiarthroplasty include the following[13, 14, 15] :

• Pain for glenohumeral osteoarthritis that has failed conservative therapy with sparring of the glenoid articular surface
• Any form of glenohumeral arthritis with inadequate glenoid bone stock when a glenoid component would otherwise be indicated
• Patients at risk for glenoid component loosening (younger patients, patients requiring heavy usage of their shoulder)

In current practice, TSA is increasingly supplanting hemiarthroplasty for the treatment of glenohumeral osteoarthritis. The 2020 guidelines from the American Academy of Orthopaedic Surgeons (AAOS) stated that in this setting, anatomic TSA demonstrates more favorable function and pain relief in short-term to midterm follow-up as compared with hemiarthroplasty.[16]

Acute fracture indications for hemiarthroplasty include the following:

• Neer four-part fractures ^{[17, 18]}
• Neer three-part fractures ^{[17, 18]} when open reduction and internal fixation (ORIF) is complicated by poor bone quality
• Neer three- and four-part fractures with concomitant humeral head dislocation ^[19]

It has been suggested that reverse shoulder arthroplasty may be a better choice for proximal humeral fractures than hemiarthroplasty is.[20, 21]  However, many factors have been found to be capable of affecting treatment of proximal humerus fractures, one of which is surgeon volume.[22] For many elderly patients, nonoperative treatment of proximal humerus fractures may be a viable option, decreasing the risk of death and adverse events.[23] In addition, operative decisions have been found to be influenced by the surgeon's specialty (shoulder surgeon vs trauma surgeon).[24]

The following chronic shoulder diseases may be indications for hemiarthroplasty.[19]

Primary osteoarthritis

Patients with primary glenohumeral osteoarthritis typically complain of joint stiffness, crepitus, and pain. Hallmark radiographic findings include a loss of joint space, subchondral cysts, sclerosis, and osteophyte formation. Rotator cuff and deltoid function may be normal or abnormal and must be assessed. Patients with adequate glenoid bone stock and an intact rotator cuff usually benefit from TSA as compared with hemiarthroplasty.

In a large study comparing hemiarthroplasty to total shoulder arthroplasty, Pfahler et al[25] found that for 102 shoulders treated with hemiarthroplasty and 418 with TSA, both functional and subjective outcomes were better with TSA than with hemiarthroplasty.

In a prospective randomized trial involving 51 shoulders, Gartsman et al[26] determined that TSA resulted in significantly greater pain relief and internal rotation than hemiarthroplasty but was associated with increased cost, operating time, and blood loss.

Similarly, in a meta-analysis of 112 shoulders treated for osteoarthritis, Bryant et al[27] found that TSA offered better functional outcomes and decreased pain when compared with hemiarthroplasty at 2-year follow-up.

Furthermore, Eichinger et al found that in patients aged 50 years or younger, TSA offered higher satisfaction than hemiarthroplasty did.[28] For TSA and hemiarthroplasty, the satisfaction survival rates at 5 years were 95% and 71.6%, respectively. Additionally, TSA had a higher implant survival rate than hemiarthroplasty did (95% vs 89%).

TSA has increasingly been favored over hemiarthroplasty for treatment of glenohumeral osteoarthritis.[16]

Inflammatory arthropathies

The most common inflammatory arthropathy affecting the shoulder is rheumatoid arthritis. Clinical findings at the glenohumeral joint are similar to osteoarthritis. However, patients may present at a younger age and with more advanced joint destruction. Hemiarthroplasty is considered when glenoid bone stock is inadequate for total or reverse total arthroplasty.

Pfahler et al[25] determined that functional outcomes for TSA were superior to those for hemiarthroplasty in 49 rheumatoid shoulders treated with hemiarthroplasty and 107 treated with TSA.

Similarly, Sperling et al[29] determined that TSA provided significantly greater pain relief and abduction than hemiarthroplasty in the setting of an intact rotator cuff for rheumatoid patients.

Instability arthritis

Patients with primary or recurrent dislocation are at an increased risk for the development of glenohumeral osteoarthritis. Patients treated surgically for instability also demonstrate increased rates of glenohumeral osteoarthritis. Although a less common entity than primary osteoarthritis and rheumatoid arthritis, instability arthritis frequently presents before the age of 50. The choice between hemiarthroplasty and TSA is controversial in these patients.

Pfahler et al[25] showed that TSA has superior functional outcomes compared withhemiarthroplasty, but these results did not reach statistical significance.

Avascular necrosis of humeral head

Avascular necrosis (AVN) remains one of the major indications for hemiarthroplasty. Typically associated with alcoholism, corticosteroid use, radiation therapy, and sickle cell anemia, AVN presentation can vary widely, but patients frequently complain of pain in the setting of a functioning rotator cuff on physical examination. Plain film findings vary from normal to subtle lucency to complete osseous collapse. In deciding between hemiarthroplasty and TSA for the treatment of AVN, it appears that resurfacing of the glenoid is typically not necessary, except possibly in the setting of advanced arthritis.[25, 30]

Rotator cuff tear arthropathy

Patients with an irreparable rotator cuff tear in the presence of glenohumeral osteoarthritis present with pain and markedly decreased elevation. Plain films may show a complete loss of the subacromial space with the humeral head articulating with the undersurface of the acromion. Because hemiarthroplasty is inferior to reverse total arthroplasty for this condition in terms of functional outcome,[31] hemiarthroplasty is typically reserved for the case where glenoid bone stock is insufficient for glenosphere implantation. TSA is contraindicated for risk of glenoid component loosening secondary to eccentric loading.

Glenohumeral chondrolysis

Chondrolysis is rare condition sometimes seen following previous shoulder intervention and presents with pain and stiffness. Muscle strength testing is typically normal and, with the exception of loss of joint space, radiographic findings of osteoarthritis are absent. Because of the frequently younger age of presentation in many of these patients, some surgeons may opt for biologic resurfacing of the glenoid with hemiarthroplasty.[19, 32] Other indications for biologic resurfacing include primary osteoarthritis, posttraumatic osteoarthritis, or postreconstructive osteoarthritis in young, active patients. Previously used biologic surfaces include anterior capsule, fascia lata autograft, and Achilles tendon allograft.[33, 34]

Tumor

Although an exceptionally rare indication, tumors requiring resection of the humeral head may be amenable to hemiarthroplasty. When rotator cuff function is severely affected by the resection, however, reverse total arthroplasty may be preferred.[19]

Contraindications for hemiarthroplasty can be divided into relative and absolute contraindications. Absolute contraindications include the following:

• Active infection
• Neuropathic shoulder
• Ankylosed shoulder
• Previous glenohumeral arthrodesis
• Incongruent glenoid and humeral surfaces
• Severe loss of glenoid articular cartilage
• Fracture treatable with ORIF
• Nondisplaced fractures treatable nonoperatively
• Unmotivated patient

Relative contraindications include the following:

• Poor surgical candidate due to general medical health
• Deltoid paralysis
• Unrealistic patient expectations

Procedural planning

The glenohumeral joint is a ball-and-socket articulation between the glenoid fossa of the scapula and the humeral head. Lacking any inherent stability, it is the most mobile joint in the human body. As such, the glenohumeral joint relies on both static and dynamic stabilizers for proper function. Dynamic stabilization and proper function is largely dependent on a functional, intact rotator cuff and its interaction with the deltoid. Reconstruction of the humeral head using good anatomic approximation is critical for optimization of shoulder biomechanics, particularly with respect to rotator cuff function, deltoid function, and soft-tissue balance.

Iannotti et al defined many of the crucial anatomic measurements used to construct modular prostheses for optimal reconstruction of normal anatomy.[35] They found the average radius of curvature of the humeral head in the coronal plane to be 24 ± 2.1 mm (range, 19-28 mm). Average humeral head thickness was 19 ± 2.1 mm (range, 15-24 mm). Lateral humeral offset, or the distance from the base of the coracoid process to the most lateral part of the greater tuberosity, averaged 56 ± 5.7 mm (range, 43-67 mm).

Boileau and Walch used a three-dimensional digitizer to obtain detailed measurements on humeral head version, inclination, and offset. Their studies showed average retroversion to be 21.5º ± 15.1º (range, –10.3º to 56.5º). The average neck-shaft angle measured 129.6º (range, 123.2º to 135.8º). Medial and posterior offsets averaged 2.6 ± 1.8 mm (range, –0.8 to 6.1 mm) and 6.9 ± 2.0 mm (range, 2.9-10.8 mm), respectively.[36]

Clavert et al described a technique that employed the pectoralis major tendon insertion as a point of reference to assist in establishing the ideal height for the hemiarthroplasty prosthesis in the case of a proximal humerus fracture.[37] It is imperative to use radiographs of both shoulders in order to determine the length, diameter, and size of the patient’s humerus.

Complication prevention

Assessment of outcomes, including complications, should be considered an important aspect of any surgeon’s clinical practice. This allows surgeons to critically analyze their own strengths and weaknesses and, ideally, find ways to improve their performance, ultimately providing the best care and value for patients. 

Preoperative administration of antibiotics (cephalosporins, vancomycin, or clindamycin) can minimize the risk of bacterial infection.

Proper head positioning to avoid hyperextension of the neck can minimize risk of cervical root compression during surgery.

Accounting for up to 20% of intraoperative complications, fractures can frequently be prevented with refined surgical technique. Etiologies include excessive reaming of the humerus, overzealous impaction of the humeral canal, or placing excessive torque on the humerus to expose the glenoid.[38] Caution must be exercised, especially with osteoporotic patients and those with rheumatoid arthritis.[39]

Iatrogenic neurologic injury can be prevented by the surgeon's familiarity with the normal shoulder anatomy, meticulous surgical technique, and an acute awareness of potential anatomic variants. The majority of neurologic injuries represent neurapraxias that resolve spontaneously over time.[38]

Patient education is a critical part of the preoperative evaluation, as well as of the postoperative rehabilitation period. A multidisciplinary approach involving the surgeon, primary care physician, physician extenders, nurses, physical therapists, and occupational therapists provides the patient with the resources necessary for optimal outcomes.

Educating the patient about reasonable goals, expectations, and outcomes as well as potential complications ensures that the patient can make an informed decision and be sufficiently motivated. The physical therapist plays a critical role in educating the patient as to ongoing home exercises that will optimize and maintain the health of the shoulder replacement.

Preoperative laboratory tests are ordered on the basis of the patient’s age and medical history. Studies such as urinalysis, electrocardiography (ECG), and complete blood count (CBC) with differential are ordered for all patients older than 50 years. Patients with a medical history are counseled by primary care providers or specialists to obtain medical clearance in advance of surgery, and laboratory tests are performed at the discretion of the referred provider.

An important innovation in shoulder arthroplasty is the use of three-dimensional (3D) virtual planning programs by surgeons.[11] After computed tomography (CT) scans of the patient are uploaded, the software creates an anatomically correct, patient-specific computerized model of the shoulder joint. This allows surgeons to plan the surgery virtually and estimate the patient’s postoperative function on the basis of both their training and the suggestions made by the program.

Overall, this software helps improve outcomes, precision, efficiency, and component placement and sizing. Furthermore, it helps surgeons anticipate possible issues (eg, bony cysts or equipment needs).

After planning is complete, a customized drill guide can be ordered for use in the actual surgical procedure; this customized guide enables optimal placement of the glenoid component. Walch et al demonstrated the precision of the 3D planning software and the guides for glenoid placement.[40] This virtual planning software poses no known risks to patients and has been shown to aid surgeons in making informed operative decisions.[41] It has been used by Dr Warner at the Boston Shoulder Institute.

Various humeral components are available for hemiarthroplasty, depending on patient-specific anatomy, bone quality, and surgical indication, as follows (see the images below):

• Humeral resurfacing caps without a stem
• Fluted stem prostheses for cementing
• Press-fit cementless stemmed prostheses
• Long-stem prostheses for fracture or revision
• Stemless prosthesis
• Cobalt chrome or titanium alloy components

Levy and Copeland reported excellent results using cementless resurfacing caps for osteoarthritis of the shoulder.[42] By avoiding the use of a stemmed component, complications involving periprosthetic fracture and humeral insertion were avoided.

Modular systems offer multiple component choices to match patient-specific inclination and retroversion to restore proper anatomy. Modular systems have also revolutionized the revision of hemiarthroplasty to reverse total shoulder arthroplasty. In a revision surgery using previously implanted modular components, the humeral head can be removed from the stem and replaced with a reverse total shoulder cup component. This change-out bypasses the necessity for removing the humeral stem during the revision.

Anesthesia

Patients receive a preoperative interscalene before being taken back to the operating room to anesthetize the upper roots of the brachial plexus. This provides excellent pain control in the immediate postoperative period and permits minimization of general anesthetic during the procedure. The anesthesiologist administers general anesthesia with neuromuscular paralysis for the duration of the surgical procedure.

Positioning

The patient is placed in the modified beach-chair/semi-Fowler position with knees flexed. A McConnell headrest allows proper positioning with the patient toward the top portion of table and with the affected shoulder's arm hanging off the table edge nearest the primary surgeon. The entire arm should then be draped and prepped in meticulous sterile fashion.[43]

After hemiarthroplasty, long-term monitoring is left to the discretion of the surgeon on the basis of the stability of results after the initial 6 months of rehabilitation. Annual examinations with plain films can be scheduled to determine potential implant loosening, assess progressive glenoid wear, and clinically examine shoulder function. Any loss of function, interference with previously normal activities of daily living, or progressive shoulder pain should prompt a visit to the surgeon; these symptoms may be indicative of implant wear or failure.

Deltopectoral approach

The deltopectoral approach[10, 44] is the most commonly used approach for shoulder arthroplasty. It provides excellent humeral exposure and preserves the deltoid origin, making it an ideal approach for hemiarthroplasty. The approach begins with identification of the coracoid process.

A 10- to 15-cm incision is made from the distal tip of the coracoid process towards the deltoid insertion on the humerus. The cephalic vein is identified and dissected free of its pectoral attachment. The internervous plane is developed by retracting the deltoid and cephalic vein laterally and the pectoralis major medially. The fibrous clavipectoral fascia is incised longitudinally, lateral to the conjoint tendon of the short head of the biceps and the coracobrachialis.

If adequate exposure is not attainable with medial retraction of the conjoint tendon, the coracoid may be osteotomized prior to medial retraction and later reduced. Keeping the arm adducted during this step reduces risk of injury to the axillary sheath. Avoiding excessive retraction of the conjoint tendon minimizes risk of musculocutaneous nerve neuropraxia.

The subscapularis is identified deep to the conjoint tendon. Three small vessels delineate the inferior border of the subscapularis. These vessels are identified and ligated. Just inferior, the axillary nerve may be palpated as it courses through the quadrangular space.

External rotation of the arm moves the musculotendinous junction of the subscapularis away from the axillary nerve. The subscapularis is tagged with sutures, then divided approximately 2 cm from its lesser tuberosity attachment, near the musculotendinous junction.

The joint capsule is now visible and can be sharply incised longitudinally to afford access to the glenohumeral joint.

Humeral head replacement

The arm is externally rotated, adducted, and extended to dislocate the humeral head. The humeral head is then templated and resected with the elbow flexed to 90º and with approximately 30º of external rotation. Before resection of the humeral head, a large Homan retractor can be placed under the biceps tendon to protect the long head of the biceps tendon and the rotator cuff during resection.

The arm is then manipulated to bring the cancellous surface of the humerus into clear view. The humeral canal is then reamed with progressively larger reamers until satisfactory cortical purchase is attained. Overzealous reaming should be avoided to minimize the risk of intraoperative fracture. A body-sizing osteotome is then inserted into the reamed canal and tapped with a mallet. The tracks created will be used to accept the trial implant.

Next, align the trial stem with the tracks created by the template and insert it into the intramedullary canal. The trial head can then be placed on the trial stem. The head must lie flush with the humeral cuts. If it is not flush, more bone can be removed with the bone saw to obtain an ideal fit. The shoulder is then reduced to test flexion, extension, abduction, adduction, and stability.

Remove the acceptable trial, and assemble the final implant. The final implant is then inserted, with the template grooves used as a guide. The shoulder is then reduced, and range of motion (ROM) can be rechecked to ensure that no impingement is present. The joint is then thoroughly irrigated.

Closure

Under neutral rotation, the subscapularis is repaired. The deltopectoral interval is then closed with interrupted absorbable sutures. The subcutaneous layer is approximated with interrupted absorbable sutures. Finally, the skin can be closed with absorbable running subcuticular sutures.

Pain management

A pain medication (eg, oxycodone) is prescribed at the surgeon’s discretion, depending the patient's level of pain and ability to tolerate it. It is suggested that the process of weaning the patient from the pain medication should begin a few days after the operation.

The initial goal of postoperative rehabilitation is to maximize passive ROM while allowing the reattached subscapularis to heal. Passive ROM exercises are started on the first day after surgery.

At the first postoperative follow-up visit (usually 10-14 days after surgery), the patient is given a prescription for physical therapy focusing on developing passive ROM. The physical therapist should also educate the patient regarding home exercises for the first 6 weeks.

Active ROM is encouraged and advanced as tolerated after the initial 6-week interval. With good passive ROM, strengthening of the deltoid, rotator cuff, and scapular stabilizers is instituted. Patients should progress as tolerated with active ROM and strengthening over the 6- to 12-week interval.

Over the 12- to 24-week interval, strengthening exercises continue, and the patient should be returning to normal activities of daily living. Continued strengthening exercises beyond the 24-week interval are recommended. Although most improvement will be seen over the first 24 weeks, functional improvement may continue to be seen for up to 1 year.

The postoperative rehabilitation approach implemented by Dr Warner at the Boston Shoulder Institute comprises four phases, as follows:

• Phase I - The patient will remain in a shoulder immobilizer for 4 weeks; during this time, pendulum exercises will be permitted, and passive ROM will be begun by the therapist formally on return at 1 week; the only limit to passive motion will be external rotation to 40º
• Phase II - At 4 weeks, the sling will be removed so that the patient can use the arm for daily living activities, including washing, dressing, and driving; self-assisted stretching will supplement the stretching done by the therapist
• Phase III - At 8 weeks, therapy will consist of progressive strengthening
• Phase IV - At 16 weeks, the patient will be allowed to exercise skilled sports

Progressive glenoid arthrosis

Progressive degeneration of the glenoid cartilage subsequent to hemiarthroplasty remains one of the most frequent complications seen after hemiarthroplasty. Younger patients placing higher demand on their shoulder are predictably at risk. Wear of the glenoid cartilage following hemiarthroplasty correlates with a poorer Constant score[45] and may necessitate conversion to total shoulder arthroplasty (TSA).

Instability

Instability following hemiarthroplasty is one of the relatively more common postoperative complications. Damage or dysfunction of any passive or active shoulder stabilizers can lead to instability. A thorough evaluation of the joint is paramount for determining the underlying cause of instability. Etiologies include component malposition, deltoid dysfunction, inadequate subscapularis repair or rupture, and soft-tissue imbalance.[38]

Infection

Infection is a relatively uncommon but potentially devastating complication of hemiarthroplasty.[38, 46] Dr Warner has observed a 0.24% rate of infection after hemiarthroplasty over the course of 1 year (Warner JJP, personal communication, 2018). Arthroscopic tissue culture appears to be more reliable than fluoroscopically guided aspiration for determining whether a patient has a shoulder infection.[47]

Preoperative and postoperative antibiotic coverage targeting gram-positive cocci and Propionibacterium species is standard. Depending on the severity of infection, treatment can range from thorough irrigation and debridement with subsequent intravenous antibiotics to component removal. Patients may require lifelong antibiotic prophylaxis before undergoing any invasive procedure that may lead to bacteremia (eg, dental work).

Aseptic loosening

Although radiolucency at the bone-cement interface is not uncommon, progression and clinical symptoms necessitating revision surgery are rare.[34]

Nerve and muscle dysfunction

Preserving deltoid function is a critical portion of hemiarthroplasty. Deltoid dysfunction, caused either by axillary nerve injury or by deltoid dehiscence, results in loss of function and pain. Dr Warner has observed a 0.71% rate of nerve injury after hemiarthroplasty over the course of 1 year (Warner JJP, personal communication, 2018). 

Heterotopic ossification

Heterotopic ossification is more common in the shoulder treated with hemiarthroplasty for humeral fracture. Severely injured soft tissues during the initial trauma and delayed surgical intervention are associated with higher rates of heterotopic ossification, though it typically is not clinically significant.

Hypotension

YaDeau et al found that hypotension occurred frequently during shoulder arthroscopy performed in the sitting position with regional anesthesia; however, cerebral oximetry desaturation was uncommon.[48]

Use of an antihypertensive medication preoperatively has been shown to increase the incidence of intraoperative hypotension during shoulder arthroscopy performed in the sitting position.[49] To maintain normal blood pressure, these patients are expected to require vasopressors more often.

Nonunion and malunion

In the setting of hemiarthroplasty for fracture, the risk of fracture nonunion or malunion is increased, particularly in those with poor bone quality. Boileau et al found that as many as 50% of shoulders reconstructed with hemiarthroplasty following displaced fractures demonstrated tuberosity malposition, which correlated with unsatisfactory result, stiffness or weakness, and pain.[50]

With osteotomy of the greater tuberosity, outcomes have been found to be poor and unpredictable.[51] Revision surgery with bone grafting may be necessary for proper fracture healing. In the setting of greater tuberosity resorption, conversion to a reverse total shoulder prosthesis may provide some improvement.[48]

Periprosthetic fracture

Postoperative periprosthetic fracture is more common in the elderly and osteoporotic. It frequently occurs as the result of trauma from falls. Stable fractures may be treated nonoperatively. However, surgical intervention is warranted with any unstable periprosthetic fracture.

Persistent pain

Identifying the cause of persistent pain following hemiarthroplasty is the most important step in determining future treatment. In many cases, the cause of persistent pain may be due to one of the aforementioned complications. Once the surgeon determines the appropriate cause, either surgical or nonsurgical interventions may be undertaken to improve both pain and quality of life.

In cases of failed hemiarthroplasty, several therapeutic options are available, including conservative treatment, arthroscopic debridement, PROSTALAC (prosthesis of antibiotic-loaded acrylic cement), resection arthroplasty, revision hemiarthroplasty with bony and/or soft-tissue reconstruction, shoulder arthrodesis, and revision to a reverse shoulder arthroplasty (RSA), which has been described by Parnes et al.[52]

Reverse shoulder arthroplasty

Levy et al reported on 19 failed shoulder hemiarthroplasties with rotator cuff arthropathy.[53] After revision to a reverse prosthesis, patients were found to have significant improvements in forward flexion and abduction, American Shoulder and Elbow Surgeons (ASES) shoulder score, and Visual Analogue Scale (VAS) score for pain, which indicated satisfactory results of the RSA for salvage after failed hemiarthroplasty.

Prosthesis of antibiotic-loaded acrylic cement

Patients presented with infection after hemiarthroplasty may be considered for PROSTALAC insertion. Jawa et al reported a series of 28 patients who underwent PROSTALAC insertion for treatment of an infection after shoulder arthroplasty.[54] Infection was initially eradicated in 82% of the patient cohort, demonstrating that PROSTALAC for the treatment of infection following shoulder arthroplasty is beneficial.

Resection arthroplasty

When revision arthroplasty is not feasible, resection arthroplasty has been used as a salvage option to restore function and relieve pain. In a retrospective review of 26 patients who underwent resection arthroplasty, Muh et al demonstrated a significant improvement in VAS scores and moderate decreases in active forward flexion and external rotation.[55]