TECHNIQUE

Hemiarthroplasty for Proximal Humerus Fractures

Emilie V. Cheung, MD

hemiarthroplasty for these fractures. A well-performed hemiarthroplasty

Abstract: Fractures of the proximal humerus are most commonly
treated nonoperatively. Displaced 3-part or 4-part proximal humeral
fractures in elderly patients are best treated with arthroplasty. Despite the
increased utilization of reverse shoulder arthroplasty, hemiarthroplasty
for the treatment of these fractures has traditionally been the gold
standard. It is important to understand the key concepts of performing a
may outperform other surgical options in nonelderly patients.
Key Words: hemiarthroplasty, proximal humeral fracture, arthro-
plasty, shoulder, proximal humerus fracture
(Tech Should Elb Surg 2016;17: 110–115)

FIGURE 1. A, Preoperative anteroposterior (AP) radiograph of right shoulder with 4-part fracture. B, Preoperative 3 dimensional
computed tomographic scan of the same right shoulder. C, Postoperative AP radiograph after hemiarthroplasty performed for
fracture.

From the Department of Orthopedic Surgery, Stanford University, Redwood City, CA.
The author declares no conflict of interest.
Reprints: Emilie Cheung, MD, Department of Orthopedic Surgery, Stanford University, Redwood City 94063, CA (e-mail: evcheung@stanford.edu).
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Techniques in Shoulder & Elbow Surgery  Volume 17, Number 3, September 2016 Hemiarthroplasty for Proximal Humerus Fractures

F ractures of the proximal humerus are one of the most

common factors encountered for osteopenic patients, after
hip fractures and distal radius fractures.1,2 The vast majority of
proximal humeral fractures are treated nonoperatively with
satisfactory results in elderly patients. Open reduction internal
fixation of proximal humeral fractures is the preferred method
of treatment for displaced fractures. If the fracture is com-
minuted, such as in some 3-part or 4-part fractures, it may not
be amenable to fixation. Hemiarthroplasty has been the gold
standard for irreparable proximal humeral fractures in elderly
patients or those patients with osteopenic bone.3–8 Hemi-
arthroplasty is currently the gold standard treatment for
irreparable fractures in patients who have higher functional
demands on their shoulders. Recent literature shows that the
utilization of hemiarthroplasty has markedly diminished over
the past few years, compared with reverse shoulder arthro-
plasty9–12 for the treatment of proximal humeral fractures in
elderly patients.
However, many shoulder surgeons would agree that a
well-performed hemiarthroplasty is preferable to a reverse total
shoulder arthroplasty. Hemiarthroplasty is more anatomic and
not constrained and is less likely to have inherent implant-
related complications specific to reverse shoulder arthroplasty,
such as scapular notching and glenoid component-related
complications. Irreparable proximal humeral fractures in
younger active patients should be treated with hemiarthroplasty
rather than reverse shoulder arthroplasty because the long-term
outcomes for reverse total shoulder are limited, and compli-
cation rates with reverse shoulder arthroplasty are higher.13–15 FIGURE 3. The fractured humeral head fragment is extracted
Historically speaking, hemiarthroplasty performed for from the glenohumeral joint. The greater and lesser tuberosities
proximal humerus fractures is very reliable for pain control.3–8 are each tagged with heavy suture with their associated rotator
Careful review of the historic literature shows that the pain cuff attachments.
section of the postoperative shoulder assessment is very low.
However, overhead motion is less reliably achieved. On cuff insertions. Therefore, the technical aspects of surgery
average, the active forward elevation in these studies is about depend upon optimization of tuberosity healing.
90 degrees, with a large range of variability. The most Modern hemiarthroplasty implants have a lower-profile
important factor for achieving active overhead motion is metaphysis, to allow more room for bone graft placement
tuberosity healing. The tuberosities contain the relative rotator along the tuberosities.16 Many of the implants available now
are also “platform” stems, which theoretically, can be later
converted to a reverse shoulder arthroplasty if there is poor
result. For example, if there is tuberosity malunion or resorp-
tion with associated rotator cuff dysfunction, then the humeral
head piece can be removed. The stem is maintained within the
humeral diaphysis, and a glenosphere can then be placed.

INDICATIONS FOR SURGERY

Indications for surgery are irreparable proximal humerus
fracture in patients of middle to older age group.

CONTRAINDICATIONS FOR SURGERY

Contraindications for surgery are an active systemic
infection or coexistent active infectious process, or an altered
mental status which would preclude abiding by postoperative
restrictions.

FIGURE 2. Deltopectoral approach for a left shoulder for
proximal humeral fracture. The biceps tendon is identified
underneath the scissors.
SURGICAL TECHNIQUE
Patient is placed into the modified beach chair position,
with the waist at 45 degrees of flexion. The shoulder down to
the fingertips is prepped and draped in the usual sterile manner.
The arm is placed into an arm holder. An impervious surgical
drape is applied.
Intraoperative fluoroscopy may be utilized while per-
forming hemiarthroplasty for assessing implant alignment and
tuberosity reduction. It is important during set-up, and before

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Cheung Techniques in Shoulder & Elbow Surgery  Volume 17, Number 3, September 2016

FIGURE 4. A, Bone graft “cookie cutter” which removes cancellous bone from the humeral head autograft. B, Fracture stem for
hemiarthroplasty, with bone graft placed within the metphysis.

sterile draping, to be able to get the fluoroscopy C-arm unit A standard deltopectoral approach is utilized. The ceph-
into the shoulder region for a proper anterior-posterior view of alic vein is retracted laterally or medially depending on sur-
the glenohumeral joint, as well as a good axillary view. It is in geon preference, and protected. Next, the subacromial-
our routine practice to bring the C-arm in from the contra-
lateral side. The television monitor for the C-arm is positioned
toward the foot of the operating room table.

FIGURE 6. Hemiarthroplasty implant with heavy suture within

the supraspinatus/infraspinatus/greater tuberosity seen
FIGURE 5. Hemiarthroplasty trial implant within the left superiorly, as well as the supscapularis/lesser tuberosity seen
shoulder. medially.

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Techniques in Shoulder & Elbow Surgery  Volume 17, Number 3, September 2016
FIGURE 7. Morcellized bone graft taken from the humeral head
is placed along the metaphyseal region of the prosthesis
underneath where the greater tuberosity belongs.
subdeltoid space is gently developed. Organized fracture
hematoma is evacuated and removed to identify the bony
anatomy along the fracture lines. A deltoid retractor is placed
to adequately visualize the fracture fragments.
The first and most important landmark initially is to identify
the biceps tendon. It is located along the biceps groove, and tra-
verses the rotator interval. The rotator interval is incised as the initial
arthrotomy. Sometimes the biceps can be incarcerated within the
fracture site, and may impede reduction of the greater tuberosity to
the anterior humeral shaft. Therefore, we usually tenotomize the
biceps tendon at its origin at the superior glenoid, and tenodese it to
the upper portion of the pectoralis major. Tenotomizing and
removing the biceps also provides better visualization into the
glenohumeral joint. Once the rotator interval is incised, we are then
able to separate the lesser tuberosity and subscapularis unit from the
greater tuberosity and supraspinatus and infraspinatus unit. The
subscapularis is tagged with heavy #5 nonabsorbable suture at the
bone tendon junction. Similarly, the supraspinatus infraspinatus is
also tagged with heavy suture at its bone tendon junction. The
subscap/lesser tuberosity union is then retraced anteriorly, and the
supraspinatus/infraspinatus/greater tuberosity is then retracted pos-
teriorly. The humeral head then can be identified. If it is a varus or
valgus impacted fracture, the humeral head may be deeply impacted
into the shaft of the humerus, and can be removed carefully by
levering it out with a large periosteal elevator. If it is a chronic
fracture, it may be grossly displaced posteriorly and adherent to the
posterior capsule. If there is head-splitting component, or commi-
nution, the head may need to be extracted carefully in pieces.
Sometimes there is a large remnant of humeral head still attached to
the greater tuberosity, which needs to be removed. Care is taken to
remove the entirety of the humeral head such that it can be
reconstructed on the back table for proper sizing of the head of the
hemiarthroplasty implant. It is important to save all cancellous bone
taken from the humeral head so that it can be morcellized for later
bone grafting into the metaphysis of the implant and underneath the
greater and lesser tuberosities before final closure toward the end of
the case.
The humeral canal can then be visualized. The humeral
stem reamers and broaches are then placed within the canal
sequentially for proper sizing. The stem size is determined.
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Hemiarthroplasty for Proximal Humerus Fractures
A technical portion of the operation is considering where
the humeral stem should be placed in terms of version and
height. The proper height can be determined based on 4 factors.
The first is its relationship to the pectoralis major tendon. One
study showed that the average distance from the superior aspect
of the humeral head to the superior aspect of the pectoralis
major insertion on the humerus is approximately 5.6 cm.17 The
second anatomic landmark would be the humeral neck calcar.
Medially, the level of the intact meal calcar should be at the
same level as the medial aspect of the humeral stem, if there is
no metaphyseal comminution into this region. The third land-
mark is the glenoid face. After the humeral head is extracted, an
anterior and posterior glenoid retractor can be placed to clearly
visualize the glenoid face. The center of the humeral head
implant should be at the level of the center of the glenoid. The
fourth factor for determining height of the prosthesis can be
preliminarily reduction of the tuberosities around the stem. The
greater tuberosity should be able to be brought down to the
lateral aspect of the humeral shaft along the metaphyseal por-
tion of the humeral trial without any undue tension. Similarly,
this can be performed for the lesser tuberosity such that there is
good overlay of the tuberosities around the metaphysis of the
stem to ensure there will be no bony gap between the tuber-
osities relative to one another, and the humeral shaft.
In our practice, we do not routinely obtain contralateral
humeral radiographs for determining the length of humeral
component in hemiarthroplasty for fracture. However, this has
been described in the literature.
Humeral head sizing is based on the diameter of the native
humeral head. If the head is in between sizes it is wise to
undersize rather than oversize. Oversizing the humeral head
may not allow for the tuberosities to be reduced around the
metaphysis of the implant to ensure proper tuberosity healing,
and puts greater tension along the associated rotator cuff.
Humeral component version is also an important technical
factor to attend to. It is important to reproduce native humeral
retroversion, which is 30 degrees of retroversion in relationship
to the epicondylar axis and 20 degrees retroversion in relation
to the forearm axis. Most implant systems available have a
version guide attached to the broach handle as well as the trial
inserter, such that when final cementation is performed, ana-
tomic retroversion should be restored. During trialing, it is also
important to get a preliminary reduction of the tuberosities to
the stem while planning for the ultimate version and height of
the humeral stem.
Intraoperative fluoroscopy may be utilized at the time of
trialing to ensure proper implant alignment and tuberosity reduc-
tion around the implant. The canal is then prepared for the real
implant by thoroughly washing and drying the canal. Two 2-mm
drill holes are placed along the lateral shaft such as to receive the
heavy nonabsorbable suture containing the supraspinatus/infra-
spinatus/greater tuberosity. The implant is then cemented into the
humeral canal diaphysis. Care is taken to remove extraneous
cement from the metaphysis, such that this region is available to
place bone graft between the implant and the tuberosities.
The most important final technical element is meticulous
repair of the tuberosities to the shaft. After the cement cures,
bone graft is placed between the tuberosities and the humeral
shaft. One pair of circumferential sutures should reduce the
greater tuberosity to the shaft. Another pair should circum-
ferentially repair the lesser tuberosity to the shaft. A third
vertical suture should be placed before final placement of the
prosthesis to reduce both of the tuberosities around the humeral
head to prevent superior displacement. A drain is routinely
used, and the wound is closed in layers.
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Cheung Techniques in Shoulder & Elbow Surgery  Volume 17, Number 3, September 2016

FIGURE 8. A, Illustration showing tagging of the supraspinatus/infraspinatus/greater tuborisity, and the suture placed along drill holes placed
within the humeral shaft. With permission from Nho et al18 (http://dx.doi.org/10.2106/JBJS.G.00648). B, The greater tuberosity is secured
around the stem, and to the shaft. C, The lesser tuberosity is secured around the stem. D, The final suture construct around the implant.

Postoperative Protocol
On postoperative day number 1, the patients are taught
pendulum exercises for the shoulder. Active range of motion is
allowed for elbow, wrist, and hand. No active range of motion
is allowed until 6 weeks postoperative, to allow for adequate
tuberosity healing. Strengthening is started at 3 months post-
operative. Patients are educated that the majority of their
motion improves at 3 to 6 months postoperative, and their final
motion may take a year to achieve (Figs. 1–8).
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