2. 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

3. Disclosures JBJSAm (Editorial Board) Smith & Nephew (Consultant) Integra (Consultant) DeRoyal (Consultant)

4. 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)

5. Hemiarthroplasty Older Patients Osteopenic Bone Fracture-Dislocations – > 40% Impression Defect

6. Hemiarthroplasty Technique

7. Patient Position

8. Surgical Technique Extended deltopectoral exposure: deltoid origin and insertion intact

9. Proximal Humerus Fracture Parts

10. Surgical Technique Identify the LHB and Tuberosities Evaluate the rotator cuff injury

11. Surgical Technique Remove the humeral head Evaluate the glenoid

12. Tuberosity Suture Technique Place suture at the tendon bone interface

13. Head Size Solutions –removed head is guide »thickness > radius –error towards undersize –check gross appearance

14. Position of Greater Tuberosity Height Relative to Humeral Head

15. Surgical Technique Assess the humeral height and version Trial tuberosity reduction Mark the stem position Lesser Tuberosity Height of the Greater Tuberosity 5-8 mm

16. Benefits of Titan System Press fit fracture No jig needed for stabilizing trials Varying body heights to dial in correct humeral head height

17. Head SizeSpherical Ø 38x14*41 40x15*43 42x1645 44x1648 44x1945 46x1454 46x1749 46x2047 48x1556 48x1851 48x2149 50x1953 50x2251 52x2055 *Eccentric Only Press-fit Stems Primary Proximal Bodies Head Options Small Standard Large Glenoid Options ***Any size primary or fracture body can be used with any size press fit or cemented stem

18. Tuberosity Height = Prosthetic Height Height of the Greater Tuberosity Lesser Tuberosity 5-8 mm

19. Determining Height –Superior border of Pectoralis tendon (5.6cm±0.5cm) –Side to Side comparison (x-ray) –View calcar contour (gothic arch)

20. Determining Height

21. Proximal Humerus Fracture

22. Humeral Version

23. Version Effect of Incorrect Version Too Anteverted Too Retroverted

24. 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

25. Surgical Technique Prepare the fixation sutures for ORIF of the tuberosities. –2-3 vertical and 2 horizontals, one medial one lateral

26. Surgical Technique Tuberosity fixation and bone graft Biceps tenodesis Wound drains and closure

27. Surgical Technique

28. 4 Part Fracture Repair

29. Factors Affecting Outcome Bone density Rotator cuff tissue quality Tuberosity healing Restoration of anatomic humeral head height Restoration of anatomic humeral version Rehabilitation

30. 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

31. Thank You